Ryan Holliday, PhD

Veterans who interact with the criminal justice system (ie, justice-involved veterans) have heightened rates of mental health and psychosocial needs, including posttraumatic stress disorder (PTSD), substance use disorder, depression, suicidal ideation and attempt, and homelessness.^1,2 Alongside these criminogenic risk factors, recidivism is common among justice-involved veterans: About 70% of incarcerated veterans disclosed at least one prior incarceration.³

To address the complex interplay of psychosocial factors, mental health concerns, and justice involvement among veterans, veterans treatment courts (VTCs) emerged as an alternative to incarceration.⁴ VTC participation often consists of integrated treatment and rehabilitative services (eg, vocational training, health care), ongoing monitoring for substance use, graduated responses to address treatment adherence, and ongoing communication with the judge and legal counsel.⁴

A primary aim of these courts is to address psychosocial needs believed to underlie criminal behavior, thus reducing risk of recidivism and promoting successful recovery and community integration for eligible veterans. To do so, VTCs collaborate with community-based and/or US Department of Veterans Affairs services, such as the Veterans Justice Outreach program (VJO). VJO specialists identify and refer justice-involved veterans to Veterans Health Administration (VHA) and community care and serve as a liaison between VTC staff and VHA health care professionals (HCPs).⁵

VTC outcome studies highlight the importance of not only diverting veterans to problem-solving courts, but also ensuring their optimal participation. Successful graduates of VTC programs demonstrate significant improvements in mental health symptoms, life satisfaction, and social support, as well as lower rates of law enforcement interactions.^6,7 However, less is known about supporting those veterans who have difficulty engaging in VTCs and either discontinue participation or require lengthier periods of participation to meet court graduation requirements.⁸ One possibility to improve engagement among these veterans is to enhance court practices to best meet their needs.

In addition to delivering treatment, VHA mental health professionals may serve a critical interdisciplinary role by lending expertise to support VTC practices. For example, equipping court professionals with clinical knowledge and skills related to motivation may strengthen the staff’s interactions with participants, enabling them to address barriers as they arise and to facilitate veterans’ treatment adherence. Additionally, responsiveness to the impact of trauma exposure, which is common among this population, may prove important as related symptoms can affect veterans’ engagement, receptivity, and behavior in court settings. Indeed, prior examinations of justice-involved veterans have found trauma exposure rates ranging from 60% to 90% and PTSD rates ranging from 27% to 40%.^1,2 Notably, involvement with the justice system (eg, incarceration) may itself further increase risk of trauma exposure (eg, experiencing a physical or sexual assault in prison) or exacerbate existing PTSD.⁹ Nonetheless, whereas many drug courts and domestic violence courts have been established, problem-solving courts with a specialized focus on trauma exposure remain rare, suggesting a potential gap in court training.

VHA HCPs have the potential to facilitate justice-involved veterans’ successful court and treatment participation by coordinating with VJO specialists to provide training and consultation to the courts. Supporting efforts to effectively and responsively address criminogenic risk (eg, mental health) in VTC settings may in turn reduce the likelihood of recidivism.¹⁰ Given the elevated rates of trauma exposure among justice-involved veterans and the relative lack of trauma-focused VTCs, we developed a trauma-informed training for VTC professionals that centered on related clinical presentations of justice-involved veterans and frequently occurring challenges in the context of court participation.

Program Development

This educational program aimed to (1) provide psychoeducation on trauma exposure, PTSD, and existing evidence-based treatments; (2) present clinical considerations for justice-involved veterans related to trauma exposure and/or PTSD; and (3) introduce skills to facilitate effective communication and trauma-informed care practices among professionals working with veterans in a treatment court.

Prior to piloting the program, we conducted a needs assessment with VTC professionals and identified relevant theoretical constructs and brief interventions for inclusion in the training. Additionally, given the dearth of prior research on mental health education for VTCs, the team consulted with the developers of PTSD 101, a VHA workshop for veterans’ families that promotes psychoeducation, support, and effective communication.¹¹ Doing so informed approaches to delivering education to nonclinical audiences that interact with veterans with histories of trauma exposure. As this was a program development project, it was determined to be exempt from institutional review board review.

Needs Assessment

In the initial stages of development, local VJO specialists identified regional VTCs and facilitated introductions to these courts. Two of the 3 Rocky Mountain region VTCs that were contacted expressed interest in receiving trauma-informed training. Based on preliminary interest, the facilitators conducted a needs assessment with VJO and VTC staff from these 2 courts to capture requests for specific content and past experiences with other mental health trainings.

Guided by the focus group model, the needs assessments took place during three 1-hour meetings with VJO specialists and a 1-hour meeting with VJO specialists, VTC professionals, and community-based clinical partners.¹² Additionally, attending a VTC graduation and court session allowed for observations of court practices and interactions with veterans. A total of 13 professionals (judges, court coordinators, case managers, peer mentors, VJO specialists, and clinicians who specialize in substance use disorder and intimate partner violence) participated in the needs assessments.

The most critical need identified by court professionals was a focus on how to apply knowledge about trauma and PTSD to interactions with justice-involved veterans. This was reportedly absent from prior training sessions the courts had received. Both Rocky Mountain region VTCs expressed a strong interest in and openness to adapting practices based on research and practice recommendations. Additional requests that emerged included a refresher on psychoeducation related to trauma and how to address the personal impact of working with this population (eg, compassion fatigue).

Training Components

Based on the needs identified by VTC professionals and informed by consultation with the developers of PTSD 101,

Fostering court familiarity with cognitive processing therapy and prolonged exposure may bolster veteran engagement in treatment through regular reinforcement of skills and concepts introduced in therapy. This may prove particularly salient given the limited engagement with mental health treatment and elevated dropout rates from PTSD treatment among the general veteran population.^15,16

Exercises and metaphors were used to illustrate concepts in multiple ways. For example, training attendees engaged in a “stop, drop, and roll” thought exercise in which they were asked to brainstorm behavioral reactions to catching on fire. This exercise illustrated the tendency for individuals to revert to common yet unhelpful attempts at problem solving (eg, running due to panic, which would exacerbate the fire), particularly in crisis and without prior education regarding adaptive ways to respond. Attendee-generated examples, such as running, were used to demonstrate the importance of practicing and reinforcing skill development prior to a crisis, to ensure proficiency and optimal response. Additionally, in prompting consideration of one’s response tendencies, this exercise may engender empathy and understanding for veterans.

Skills training. Efforts to promote veteran engagement in court, facilitate motivation and readiness for change, and address barriers that arise (eg, distress associated with court appearances) may support successful and timely graduation. As such, skills training constituted the largest component of the training and drew from observations of court practices and the VTCs’ identified challenges. Consistent with the project’s aims and reported needs of the court, skills that target common presentations following trauma exposure (eg, avoidance, hypervigilance) were prioritized for this pilot training. Strategies included brief interventions from dialectical behavior therapy, acceptance and commitment therapy, and motivational interviewing to strengthen the support provided by staff to veterans and address their needs (Table 2).

Training attendees also participated in exercises to reiterate skills. For example, attendees completed an ambivalence matrix using an audience-identified common behavior that is difficult to change (eg, heavy alcohol use as a coping mechanism for distress).

Attendees engaged in an exercise that involved identifying unhelpful thoughts and behaviors, targets for validation, and veteran strengths from a hypothetical case vignette. This vignette involved a VTC participant who initially engaged effectively but began to demonstrate difficulty appropriately engaging in court and mental health treatment as well as challenging interactions with VTC staff (eg, raised voice during court sessions, not respecting communication boundaries).

Pilot Test

Based on scheduling parameters communicated by court coordinators, the pilot training was designed as a presentation during times reserved for court staffing meetings. To accommodate court preferences due to the COVID-19 pandemic, one 90-minute training was conducted virtually in March 2022, and the other training was conducted in person in April 2022 for 2 hours. The trainings were facilitated by 2 VHA clinical psychologists and included the judge, court coordinator, VJO specialist, peer mentors, case managers, probation/parole officers, and community-based HCPs who partner with the court (eg, social workers, psychologists). About 12 to 15 professionals attended each training session.

Feedback

Feedback was solicited from attendees via an anonymous online survey. Seven participants completed the survey; the response rate of about 20% was consistent with those observed for other surveys of court professionals.²⁰ Many attendees also provided feedback directly to the facilitators. Feedback highlighted that the skills-based components not only were perceived as most helpful but also notably distinguished this training. “What set this training apart from other training events was the practical applications,” one attendee noted. “It was not just information or education, both instructors did an incredible job of explaining exactly how we could apply the knowledge they were sharing. They did this in such a way that it was easy to understand and apply.”

Specific skills were consistently identified as helpful, including managing intense emotions, addressing ambivalence, and approaching sanctions and rewards. Additionally, employing a less formal approach to the training, with relatable overviews of concepts and immediate responsiveness to requests for expansion on a topic, was perceived as a unique benefit: Another attendee appreciated that “It was beneficial to sit around a table with a less formal presentation and be able to ask questions.” This approach seemed particularly well suited for the program’s cross-disciplinary audience. Attendees reported that they valued the relatively limited focus on DSM-5 criteria. Attendees emphasized that education specific to veterans on evidence-based PTSD treatments, psychoeducation, and avoidance was very helpful. Respondents also recommended that the training be lengthened to a daylong workshop to accommodate greater opportunity to practice skills and consultation.

The consultation portion of the training provided insight into additional areas of importance to incorporate into future iterations. Identified needs included appropriate and realistic boundary setting (eg, addressing disruptions in the courtroom), suggestions for improving and expanding homework assigned by the court, and ways to address concerns about PTSD treatment shared by veterans in court (eg, attributing substance use relapses to the intensiveness of trauma-focused treatment vs lack of familiarity with alternate coping skills). Additionally, the VTC professionals’ desire to support mental health professionals’ work with veterans was clearly evident, highlighting the bidirectional value of interdisciplinary collaboration between VHA mental health professionals and VTC professionals.

Discussion

A trauma-informed training was developed and delivered to 2 VTCs in the Rocky Mountain region with the goal of providing relevant psychoeducation and introducing skills to bolster court practices that address veteran needs. Psychoeducational components of the training that were particularly well received and prompted significant participant engagement included discussions and examples of avoidance, levels of validation, language to facilitate motivation and address barriers, mechanisms underlying treatment, and potential functions underlying limited veteran treatment engagement. Distress tolerance, approaches to sanctions and rewards, and use of ambivalence matrices to guide motivation were identified as particularly helpful skills.

The pilot phase of this trauma-informed training provided valuable insights into developing mental health trainings for VTCs. Specifically, VTCs may benefit from the expertise of VHA HCPs and are particularly interested in learning brief skills to improve their practices. The usefulness of such trainings may be bolstered by efforts to form relationships with the court to identify their perceived needs and employing an iterative process that is responsive to feedback both during and after the training. Last, each stage of this project was strengthened by collaboration with VJO specialists, highlighting the importance of future collaboration between VJO and VHA mental health clinics to further support justice-involved veterans. For example, VJO specialists were instrumental in identifying training needs related to veterans’ clinical presentations in court, facilitating introductions to local VTCs, and helping to address barriers to piloting, like scheduling.

Modifications and Future Directions

The insights gained through the process of training design, delivery, and feedback inform future development of this training. Based on the feedback received, subsequent versions of the training may be expanded into a half- or full-day workshop to allow for adequate time for skills training and feedback, as well as consultation. Doing so will enable facilitators to further foster attendees’ familiarity with and confidence in their ability to use these skills. Furthermore, the consultation portion of this training revealed areas that may benefit from greater attention, including how to address challenging interactions in court (eg, addressing gender dynamics between court professionals and participants) and better support veterans who are having difficulty engaging in mental health treatment (eg, courts’ observation of high rates of dropout around the third or fourth session of evidence-based treatment for PTSD). Last, all attendees who responded to the survey expressed interest in a brief resource guide based on the training, emphasizing the need for ready access to key skills and concepts to support the use of strategies learned.

An additional future aim of this project is to conduct a more thorough evaluation of the needs and outcomes related to this trauma-informed training for VTC professionals. With the rapid growth of VTCs nationwide, relatively little examination of court processes and practices has occurred, and there is a lack of research on the development or effectiveness of mental health trainings provided to VTCs.²¹ Therefore, we intend to conduct larger scale qualitative interviews with court personnel and VJO specialists to obtain a clearer understanding of the needs related to skills-based training and gaps in psychoeducation. These comprehensive needs assessments may also capture common comorbidities that were not incorporated into the pilot training (eg, substance use disorders) but may be important training targets for court professionals. This information will be used to inform subsequent expansion and adaptation of the training into a longer workshop. Program evaluation will be conducted via survey-based feedback on perceived usefulness of the workshop and self-report of confidence in and use of strategies to improve court practices. Furthermore, efforts to obtain veteran outcome data, such as treatment engagement and successful participation in VTC, may be pursued.

Limitations

This training development and pilot project provided valuable foundational information regarding a largely unexamined component of treatment courts—the benefit of skills-based trainings to facilitate court practices related to justice-involved veterans. However, it is worth noting that survey responses were limited; thus, the feedback received may not reflect all attendees’ perceptions. Additionally, because both training sessions were conducted solely with 2 courts in the Rocky Mountain area, feedback may be limited to the needs of this geographic region.

Conclusions

A trauma-informed training was developed for VTCs to facilitate relevant understanding of justice-involved veterans’ needs and presentations in court, introduce skills to address challenges that arise (eg, motivation, emotional dysregulation), and provide interdisciplinary support to court professionals. This training was an important step toward fostering strong collaborations between VHA HCPs and community-based veterans courts, and feedback received during development and following implementation highlighted the perceived need for a skills-based approach to such trainings. Further program development and evaluation can strengthen this training and provide a foundation for dissemination to a broader scope of VTCs, with the goal of reducing recidivism risk among justice-involved veterans by promoting effective engagement in problem-solving court.

Veterans who interact with the criminal justice system (ie, justice-involved veterans) have heightened rates of mental health and psychosocial needs, including posttraumatic stress disorder (PTSD), substance use disorder, depression, suicidal ideation and attempt, and homelessness.^1,2 Alongside these criminogenic risk factors, recidivism is common among justice-involved veterans: About 70% of incarcerated veterans disclosed at least one prior incarceration.³

To address the complex interplay of psychosocial factors, mental health concerns, and justice involvement among veterans, veterans treatment courts (VTCs) emerged as an alternative to incarceration.⁴ VTC participation often consists of integrated treatment and rehabilitative services (eg, vocational training, health care), ongoing monitoring for substance use, graduated responses to address treatment adherence, and ongoing communication with the judge and legal counsel.⁴

A primary aim of these courts is to address psychosocial needs believed to underlie criminal behavior, thus reducing risk of recidivism and promoting successful recovery and community integration for eligible veterans. To do so, VTCs collaborate with community-based and/or US Department of Veterans Affairs services, such as the Veterans Justice Outreach program (VJO). VJO specialists identify and refer justice-involved veterans to Veterans Health Administration (VHA) and community care and serve as a liaison between VTC staff and VHA health care professionals (HCPs).⁵

VTC outcome studies highlight the importance of not only diverting veterans to problem-solving courts, but also ensuring their optimal participation. Successful graduates of VTC programs demonstrate significant improvements in mental health symptoms, life satisfaction, and social support, as well as lower rates of law enforcement interactions.^6,7 However, less is known about supporting those veterans who have difficulty engaging in VTCs and either discontinue participation or require lengthier periods of participation to meet court graduation requirements.⁸ One possibility to improve engagement among these veterans is to enhance court practices to best meet their needs.

In addition to delivering treatment, VHA mental health professionals may serve a critical interdisciplinary role by lending expertise to support VTC practices. For example, equipping court professionals with clinical knowledge and skills related to motivation may strengthen the staff’s interactions with participants, enabling them to address barriers as they arise and to facilitate veterans’ treatment adherence. Additionally, responsiveness to the impact of trauma exposure, which is common among this population, may prove important as related symptoms can affect veterans’ engagement, receptivity, and behavior in court settings. Indeed, prior examinations of justice-involved veterans have found trauma exposure rates ranging from 60% to 90% and PTSD rates ranging from 27% to 40%.^1,2 Notably, involvement with the justice system (eg, incarceration) may itself further increase risk of trauma exposure (eg, experiencing a physical or sexual assault in prison) or exacerbate existing PTSD.⁹ Nonetheless, whereas many drug courts and domestic violence courts have been established, problem-solving courts with a specialized focus on trauma exposure remain rare, suggesting a potential gap in court training.

VHA HCPs have the potential to facilitate justice-involved veterans’ successful court and treatment participation by coordinating with VJO specialists to provide training and consultation to the courts. Supporting efforts to effectively and responsively address criminogenic risk (eg, mental health) in VTC settings may in turn reduce the likelihood of recidivism.¹⁰ Given the elevated rates of trauma exposure among justice-involved veterans and the relative lack of trauma-focused VTCs, we developed a trauma-informed training for VTC professionals that centered on related clinical presentations of justice-involved veterans and frequently occurring challenges in the context of court participation.

Program Development

This educational program aimed to (1) provide psychoeducation on trauma exposure, PTSD, and existing evidence-based treatments; (2) present clinical considerations for justice-involved veterans related to trauma exposure and/or PTSD; and (3) introduce skills to facilitate effective communication and trauma-informed care practices among professionals working with veterans in a treatment court.

Prior to piloting the program, we conducted a needs assessment with VTC professionals and identified relevant theoretical constructs and brief interventions for inclusion in the training. Additionally, given the dearth of prior research on mental health education for VTCs, the team consulted with the developers of PTSD 101, a VHA workshop for veterans’ families that promotes psychoeducation, support, and effective communication.¹¹ Doing so informed approaches to delivering education to nonclinical audiences that interact with veterans with histories of trauma exposure. As this was a program development project, it was determined to be exempt from institutional review board review.

Needs Assessment

In the initial stages of development, local VJO specialists identified regional VTCs and facilitated introductions to these courts. Two of the 3 Rocky Mountain region VTCs that were contacted expressed interest in receiving trauma-informed training. Based on preliminary interest, the facilitators conducted a needs assessment with VJO and VTC staff from these 2 courts to capture requests for specific content and past experiences with other mental health trainings.

Guided by the focus group model, the needs assessments took place during three 1-hour meetings with VJO specialists and a 1-hour meeting with VJO specialists, VTC professionals, and community-based clinical partners.¹² Additionally, attending a VTC graduation and court session allowed for observations of court practices and interactions with veterans. A total of 13 professionals (judges, court coordinators, case managers, peer mentors, VJO specialists, and clinicians who specialize in substance use disorder and intimate partner violence) participated in the needs assessments.

The most critical need identified by court professionals was a focus on how to apply knowledge about trauma and PTSD to interactions with justice-involved veterans. This was reportedly absent from prior training sessions the courts had received. Both Rocky Mountain region VTCs expressed a strong interest in and openness to adapting practices based on research and practice recommendations. Additional requests that emerged included a refresher on psychoeducation related to trauma and how to address the personal impact of working with this population (eg, compassion fatigue).

Training Components

Based on the needs identified by VTC professionals and informed by consultation with the developers of PTSD 101,

Fostering court familiarity with cognitive processing therapy and prolonged exposure may bolster veteran engagement in treatment through regular reinforcement of skills and concepts introduced in therapy. This may prove particularly salient given the limited engagement with mental health treatment and elevated dropout rates from PTSD treatment among the general veteran population.^15,16

Exercises and metaphors were used to illustrate concepts in multiple ways. For example, training attendees engaged in a “stop, drop, and roll” thought exercise in which they were asked to brainstorm behavioral reactions to catching on fire. This exercise illustrated the tendency for individuals to revert to common yet unhelpful attempts at problem solving (eg, running due to panic, which would exacerbate the fire), particularly in crisis and without prior education regarding adaptive ways to respond. Attendee-generated examples, such as running, were used to demonstrate the importance of practicing and reinforcing skill development prior to a crisis, to ensure proficiency and optimal response. Additionally, in prompting consideration of one’s response tendencies, this exercise may engender empathy and understanding for veterans.

Skills training. Efforts to promote veteran engagement in court, facilitate motivation and readiness for change, and address barriers that arise (eg, distress associated with court appearances) may support successful and timely graduation. As such, skills training constituted the largest component of the training and drew from observations of court practices and the VTCs’ identified challenges. Consistent with the project’s aims and reported needs of the court, skills that target common presentations following trauma exposure (eg, avoidance, hypervigilance) were prioritized for this pilot training. Strategies included brief interventions from dialectical behavior therapy, acceptance and commitment therapy, and motivational interviewing to strengthen the support provided by staff to veterans and address their needs (Table 2).

Training attendees also participated in exercises to reiterate skills. For example, attendees completed an ambivalence matrix using an audience-identified common behavior that is difficult to change (eg, heavy alcohol use as a coping mechanism for distress).

Attendees engaged in an exercise that involved identifying unhelpful thoughts and behaviors, targets for validation, and veteran strengths from a hypothetical case vignette. This vignette involved a VTC participant who initially engaged effectively but began to demonstrate difficulty appropriately engaging in court and mental health treatment as well as challenging interactions with VTC staff (eg, raised voice during court sessions, not respecting communication boundaries).

Pilot Test

Based on scheduling parameters communicated by court coordinators, the pilot training was designed as a presentation during times reserved for court staffing meetings. To accommodate court preferences due to the COVID-19 pandemic, one 90-minute training was conducted virtually in March 2022, and the other training was conducted in person in April 2022 for 2 hours. The trainings were facilitated by 2 VHA clinical psychologists and included the judge, court coordinator, VJO specialist, peer mentors, case managers, probation/parole officers, and community-based HCPs who partner with the court (eg, social workers, psychologists). About 12 to 15 professionals attended each training session.

Feedback

Feedback was solicited from attendees via an anonymous online survey. Seven participants completed the survey; the response rate of about 20% was consistent with those observed for other surveys of court professionals.²⁰ Many attendees also provided feedback directly to the facilitators. Feedback highlighted that the skills-based components not only were perceived as most helpful but also notably distinguished this training. “What set this training apart from other training events was the practical applications,” one attendee noted. “It was not just information or education, both instructors did an incredible job of explaining exactly how we could apply the knowledge they were sharing. They did this in such a way that it was easy to understand and apply.”

Specific skills were consistently identified as helpful, including managing intense emotions, addressing ambivalence, and approaching sanctions and rewards. Additionally, employing a less formal approach to the training, with relatable overviews of concepts and immediate responsiveness to requests for expansion on a topic, was perceived as a unique benefit: Another attendee appreciated that “It was beneficial to sit around a table with a less formal presentation and be able to ask questions.” This approach seemed particularly well suited for the program’s cross-disciplinary audience. Attendees reported that they valued the relatively limited focus on DSM-5 criteria. Attendees emphasized that education specific to veterans on evidence-based PTSD treatments, psychoeducation, and avoidance was very helpful. Respondents also recommended that the training be lengthened to a daylong workshop to accommodate greater opportunity to practice skills and consultation.

The consultation portion of the training provided insight into additional areas of importance to incorporate into future iterations. Identified needs included appropriate and realistic boundary setting (eg, addressing disruptions in the courtroom), suggestions for improving and expanding homework assigned by the court, and ways to address concerns about PTSD treatment shared by veterans in court (eg, attributing substance use relapses to the intensiveness of trauma-focused treatment vs lack of familiarity with alternate coping skills). Additionally, the VTC professionals’ desire to support mental health professionals’ work with veterans was clearly evident, highlighting the bidirectional value of interdisciplinary collaboration between VHA mental health professionals and VTC professionals.

Discussion

A trauma-informed training was developed and delivered to 2 VTCs in the Rocky Mountain region with the goal of providing relevant psychoeducation and introducing skills to bolster court practices that address veteran needs. Psychoeducational components of the training that were particularly well received and prompted significant participant engagement included discussions and examples of avoidance, levels of validation, language to facilitate motivation and address barriers, mechanisms underlying treatment, and potential functions underlying limited veteran treatment engagement. Distress tolerance, approaches to sanctions and rewards, and use of ambivalence matrices to guide motivation were identified as particularly helpful skills.

The pilot phase of this trauma-informed training provided valuable insights into developing mental health trainings for VTCs. Specifically, VTCs may benefit from the expertise of VHA HCPs and are particularly interested in learning brief skills to improve their practices. The usefulness of such trainings may be bolstered by efforts to form relationships with the court to identify their perceived needs and employing an iterative process that is responsive to feedback both during and after the training. Last, each stage of this project was strengthened by collaboration with VJO specialists, highlighting the importance of future collaboration between VJO and VHA mental health clinics to further support justice-involved veterans. For example, VJO specialists were instrumental in identifying training needs related to veterans’ clinical presentations in court, facilitating introductions to local VTCs, and helping to address barriers to piloting, like scheduling.

Modifications and Future Directions

The insights gained through the process of training design, delivery, and feedback inform future development of this training. Based on the feedback received, subsequent versions of the training may be expanded into a half- or full-day workshop to allow for adequate time for skills training and feedback, as well as consultation. Doing so will enable facilitators to further foster attendees’ familiarity with and confidence in their ability to use these skills. Furthermore, the consultation portion of this training revealed areas that may benefit from greater attention, including how to address challenging interactions in court (eg, addressing gender dynamics between court professionals and participants) and better support veterans who are having difficulty engaging in mental health treatment (eg, courts’ observation of high rates of dropout around the third or fourth session of evidence-based treatment for PTSD). Last, all attendees who responded to the survey expressed interest in a brief resource guide based on the training, emphasizing the need for ready access to key skills and concepts to support the use of strategies learned.

An additional future aim of this project is to conduct a more thorough evaluation of the needs and outcomes related to this trauma-informed training for VTC professionals. With the rapid growth of VTCs nationwide, relatively little examination of court processes and practices has occurred, and there is a lack of research on the development or effectiveness of mental health trainings provided to VTCs.²¹ Therefore, we intend to conduct larger scale qualitative interviews with court personnel and VJO specialists to obtain a clearer understanding of the needs related to skills-based training and gaps in psychoeducation. These comprehensive needs assessments may also capture common comorbidities that were not incorporated into the pilot training (eg, substance use disorders) but may be important training targets for court professionals. This information will be used to inform subsequent expansion and adaptation of the training into a longer workshop. Program evaluation will be conducted via survey-based feedback on perceived usefulness of the workshop and self-report of confidence in and use of strategies to improve court practices. Furthermore, efforts to obtain veteran outcome data, such as treatment engagement and successful participation in VTC, may be pursued.

Limitations

This training development and pilot project provided valuable foundational information regarding a largely unexamined component of treatment courts—the benefit of skills-based trainings to facilitate court practices related to justice-involved veterans. However, it is worth noting that survey responses were limited; thus, the feedback received may not reflect all attendees’ perceptions. Additionally, because both training sessions were conducted solely with 2 courts in the Rocky Mountain area, feedback may be limited to the needs of this geographic region.

Conclusions

A trauma-informed training was developed for VTCs to facilitate relevant understanding of justice-involved veterans’ needs and presentations in court, introduce skills to address challenges that arise (eg, motivation, emotional dysregulation), and provide interdisciplinary support to court professionals. This training was an important step toward fostering strong collaborations between VHA HCPs and community-based veterans courts, and feedback received during development and following implementation highlighted the perceived need for a skills-based approach to such trainings. Further program development and evaluation can strengthen this training and provide a foundation for dissemination to a broader scope of VTCs, with the goal of reducing recidivism risk among justice-involved veterans by promoting effective engagement in problem-solving court.

Veterans who interact with the criminal justice system (ie, justice-involved veterans) have heightened rates of mental health and psychosocial needs, including posttraumatic stress disorder (PTSD), substance use disorder, depression, suicidal ideation and attempt, and homelessness.^1,2 Alongside these criminogenic risk factors, recidivism is common among justice-involved veterans: About 70% of incarcerated veterans disclosed at least one prior incarceration.³

To address the complex interplay of psychosocial factors, mental health concerns, and justice involvement among veterans, veterans treatment courts (VTCs) emerged as an alternative to incarceration.⁴ VTC participation often consists of integrated treatment and rehabilitative services (eg, vocational training, health care), ongoing monitoring for substance use, graduated responses to address treatment adherence, and ongoing communication with the judge and legal counsel.⁴

A primary aim of these courts is to address psychosocial needs believed to underlie criminal behavior, thus reducing risk of recidivism and promoting successful recovery and community integration for eligible veterans. To do so, VTCs collaborate with community-based and/or US Department of Veterans Affairs services, such as the Veterans Justice Outreach program (VJO). VJO specialists identify and refer justice-involved veterans to Veterans Health Administration (VHA) and community care and serve as a liaison between VTC staff and VHA health care professionals (HCPs).⁵

VTC outcome studies highlight the importance of not only diverting veterans to problem-solving courts, but also ensuring their optimal participation. Successful graduates of VTC programs demonstrate significant improvements in mental health symptoms, life satisfaction, and social support, as well as lower rates of law enforcement interactions.^6,7 However, less is known about supporting those veterans who have difficulty engaging in VTCs and either discontinue participation or require lengthier periods of participation to meet court graduation requirements.⁸ One possibility to improve engagement among these veterans is to enhance court practices to best meet their needs.

In addition to delivering treatment, VHA mental health professionals may serve a critical interdisciplinary role by lending expertise to support VTC practices. For example, equipping court professionals with clinical knowledge and skills related to motivation may strengthen the staff’s interactions with participants, enabling them to address barriers as they arise and to facilitate veterans’ treatment adherence. Additionally, responsiveness to the impact of trauma exposure, which is common among this population, may prove important as related symptoms can affect veterans’ engagement, receptivity, and behavior in court settings. Indeed, prior examinations of justice-involved veterans have found trauma exposure rates ranging from 60% to 90% and PTSD rates ranging from 27% to 40%.^1,2 Notably, involvement with the justice system (eg, incarceration) may itself further increase risk of trauma exposure (eg, experiencing a physical or sexual assault in prison) or exacerbate existing PTSD.⁹ Nonetheless, whereas many drug courts and domestic violence courts have been established, problem-solving courts with a specialized focus on trauma exposure remain rare, suggesting a potential gap in court training.

VHA HCPs have the potential to facilitate justice-involved veterans’ successful court and treatment participation by coordinating with VJO specialists to provide training and consultation to the courts. Supporting efforts to effectively and responsively address criminogenic risk (eg, mental health) in VTC settings may in turn reduce the likelihood of recidivism.¹⁰ Given the elevated rates of trauma exposure among justice-involved veterans and the relative lack of trauma-focused VTCs, we developed a trauma-informed training for VTC professionals that centered on related clinical presentations of justice-involved veterans and frequently occurring challenges in the context of court participation.

Program Development

This educational program aimed to (1) provide psychoeducation on trauma exposure, PTSD, and existing evidence-based treatments; (2) present clinical considerations for justice-involved veterans related to trauma exposure and/or PTSD; and (3) introduce skills to facilitate effective communication and trauma-informed care practices among professionals working with veterans in a treatment court.

Prior to piloting the program, we conducted a needs assessment with VTC professionals and identified relevant theoretical constructs and brief interventions for inclusion in the training. Additionally, given the dearth of prior research on mental health education for VTCs, the team consulted with the developers of PTSD 101, a VHA workshop for veterans’ families that promotes psychoeducation, support, and effective communication.¹¹ Doing so informed approaches to delivering education to nonclinical audiences that interact with veterans with histories of trauma exposure. As this was a program development project, it was determined to be exempt from institutional review board review.

Needs Assessment

In the initial stages of development, local VJO specialists identified regional VTCs and facilitated introductions to these courts. Two of the 3 Rocky Mountain region VTCs that were contacted expressed interest in receiving trauma-informed training. Based on preliminary interest, the facilitators conducted a needs assessment with VJO and VTC staff from these 2 courts to capture requests for specific content and past experiences with other mental health trainings.

Guided by the focus group model, the needs assessments took place during three 1-hour meetings with VJO specialists and a 1-hour meeting with VJO specialists, VTC professionals, and community-based clinical partners.¹² Additionally, attending a VTC graduation and court session allowed for observations of court practices and interactions with veterans. A total of 13 professionals (judges, court coordinators, case managers, peer mentors, VJO specialists, and clinicians who specialize in substance use disorder and intimate partner violence) participated in the needs assessments.

The most critical need identified by court professionals was a focus on how to apply knowledge about trauma and PTSD to interactions with justice-involved veterans. This was reportedly absent from prior training sessions the courts had received. Both Rocky Mountain region VTCs expressed a strong interest in and openness to adapting practices based on research and practice recommendations. Additional requests that emerged included a refresher on psychoeducation related to trauma and how to address the personal impact of working with this population (eg, compassion fatigue).

Training Components

Based on the needs identified by VTC professionals and informed by consultation with the developers of PTSD 101,

Fostering court familiarity with cognitive processing therapy and prolonged exposure may bolster veteran engagement in treatment through regular reinforcement of skills and concepts introduced in therapy. This may prove particularly salient given the limited engagement with mental health treatment and elevated dropout rates from PTSD treatment among the general veteran population.^15,16

Exercises and metaphors were used to illustrate concepts in multiple ways. For example, training attendees engaged in a “stop, drop, and roll” thought exercise in which they were asked to brainstorm behavioral reactions to catching on fire. This exercise illustrated the tendency for individuals to revert to common yet unhelpful attempts at problem solving (eg, running due to panic, which would exacerbate the fire), particularly in crisis and without prior education regarding adaptive ways to respond. Attendee-generated examples, such as running, were used to demonstrate the importance of practicing and reinforcing skill development prior to a crisis, to ensure proficiency and optimal response. Additionally, in prompting consideration of one’s response tendencies, this exercise may engender empathy and understanding for veterans.

Skills training. Efforts to promote veteran engagement in court, facilitate motivation and readiness for change, and address barriers that arise (eg, distress associated with court appearances) may support successful and timely graduation. As such, skills training constituted the largest component of the training and drew from observations of court practices and the VTCs’ identified challenges. Consistent with the project’s aims and reported needs of the court, skills that target common presentations following trauma exposure (eg, avoidance, hypervigilance) were prioritized for this pilot training. Strategies included brief interventions from dialectical behavior therapy, acceptance and commitment therapy, and motivational interviewing to strengthen the support provided by staff to veterans and address their needs (Table 2).

Training attendees also participated in exercises to reiterate skills. For example, attendees completed an ambivalence matrix using an audience-identified common behavior that is difficult to change (eg, heavy alcohol use as a coping mechanism for distress).

Attendees engaged in an exercise that involved identifying unhelpful thoughts and behaviors, targets for validation, and veteran strengths from a hypothetical case vignette. This vignette involved a VTC participant who initially engaged effectively but began to demonstrate difficulty appropriately engaging in court and mental health treatment as well as challenging interactions with VTC staff (eg, raised voice during court sessions, not respecting communication boundaries).

Pilot Test

Based on scheduling parameters communicated by court coordinators, the pilot training was designed as a presentation during times reserved for court staffing meetings. To accommodate court preferences due to the COVID-19 pandemic, one 90-minute training was conducted virtually in March 2022, and the other training was conducted in person in April 2022 for 2 hours. The trainings were facilitated by 2 VHA clinical psychologists and included the judge, court coordinator, VJO specialist, peer mentors, case managers, probation/parole officers, and community-based HCPs who partner with the court (eg, social workers, psychologists). About 12 to 15 professionals attended each training session.

Feedback

Feedback was solicited from attendees via an anonymous online survey. Seven participants completed the survey; the response rate of about 20% was consistent with those observed for other surveys of court professionals.²⁰ Many attendees also provided feedback directly to the facilitators. Feedback highlighted that the skills-based components not only were perceived as most helpful but also notably distinguished this training. “What set this training apart from other training events was the practical applications,” one attendee noted. “It was not just information or education, both instructors did an incredible job of explaining exactly how we could apply the knowledge they were sharing. They did this in such a way that it was easy to understand and apply.”

Specific skills were consistently identified as helpful, including managing intense emotions, addressing ambivalence, and approaching sanctions and rewards. Additionally, employing a less formal approach to the training, with relatable overviews of concepts and immediate responsiveness to requests for expansion on a topic, was perceived as a unique benefit: Another attendee appreciated that “It was beneficial to sit around a table with a less formal presentation and be able to ask questions.” This approach seemed particularly well suited for the program’s cross-disciplinary audience. Attendees reported that they valued the relatively limited focus on DSM-5 criteria. Attendees emphasized that education specific to veterans on evidence-based PTSD treatments, psychoeducation, and avoidance was very helpful. Respondents also recommended that the training be lengthened to a daylong workshop to accommodate greater opportunity to practice skills and consultation.

The consultation portion of the training provided insight into additional areas of importance to incorporate into future iterations. Identified needs included appropriate and realistic boundary setting (eg, addressing disruptions in the courtroom), suggestions for improving and expanding homework assigned by the court, and ways to address concerns about PTSD treatment shared by veterans in court (eg, attributing substance use relapses to the intensiveness of trauma-focused treatment vs lack of familiarity with alternate coping skills). Additionally, the VTC professionals’ desire to support mental health professionals’ work with veterans was clearly evident, highlighting the bidirectional value of interdisciplinary collaboration between VHA mental health professionals and VTC professionals.

Discussion

A trauma-informed training was developed and delivered to 2 VTCs in the Rocky Mountain region with the goal of providing relevant psychoeducation and introducing skills to bolster court practices that address veteran needs. Psychoeducational components of the training that were particularly well received and prompted significant participant engagement included discussions and examples of avoidance, levels of validation, language to facilitate motivation and address barriers, mechanisms underlying treatment, and potential functions underlying limited veteran treatment engagement. Distress tolerance, approaches to sanctions and rewards, and use of ambivalence matrices to guide motivation were identified as particularly helpful skills.

The pilot phase of this trauma-informed training provided valuable insights into developing mental health trainings for VTCs. Specifically, VTCs may benefit from the expertise of VHA HCPs and are particularly interested in learning brief skills to improve their practices. The usefulness of such trainings may be bolstered by efforts to form relationships with the court to identify their perceived needs and employing an iterative process that is responsive to feedback both during and after the training. Last, each stage of this project was strengthened by collaboration with VJO specialists, highlighting the importance of future collaboration between VJO and VHA mental health clinics to further support justice-involved veterans. For example, VJO specialists were instrumental in identifying training needs related to veterans’ clinical presentations in court, facilitating introductions to local VTCs, and helping to address barriers to piloting, like scheduling.

Modifications and Future Directions

The insights gained through the process of training design, delivery, and feedback inform future development of this training. Based on the feedback received, subsequent versions of the training may be expanded into a half- or full-day workshop to allow for adequate time for skills training and feedback, as well as consultation. Doing so will enable facilitators to further foster attendees’ familiarity with and confidence in their ability to use these skills. Furthermore, the consultation portion of this training revealed areas that may benefit from greater attention, including how to address challenging interactions in court (eg, addressing gender dynamics between court professionals and participants) and better support veterans who are having difficulty engaging in mental health treatment (eg, courts’ observation of high rates of dropout around the third or fourth session of evidence-based treatment for PTSD). Last, all attendees who responded to the survey expressed interest in a brief resource guide based on the training, emphasizing the need for ready access to key skills and concepts to support the use of strategies learned.

An additional future aim of this project is to conduct a more thorough evaluation of the needs and outcomes related to this trauma-informed training for VTC professionals. With the rapid growth of VTCs nationwide, relatively little examination of court processes and practices has occurred, and there is a lack of research on the development or effectiveness of mental health trainings provided to VTCs.²¹ Therefore, we intend to conduct larger scale qualitative interviews with court personnel and VJO specialists to obtain a clearer understanding of the needs related to skills-based training and gaps in psychoeducation. These comprehensive needs assessments may also capture common comorbidities that were not incorporated into the pilot training (eg, substance use disorders) but may be important training targets for court professionals. This information will be used to inform subsequent expansion and adaptation of the training into a longer workshop. Program evaluation will be conducted via survey-based feedback on perceived usefulness of the workshop and self-report of confidence in and use of strategies to improve court practices. Furthermore, efforts to obtain veteran outcome data, such as treatment engagement and successful participation in VTC, may be pursued.

Limitations

This training development and pilot project provided valuable foundational information regarding a largely unexamined component of treatment courts—the benefit of skills-based trainings to facilitate court practices related to justice-involved veterans. However, it is worth noting that survey responses were limited; thus, the feedback received may not reflect all attendees’ perceptions. Additionally, because both training sessions were conducted solely with 2 courts in the Rocky Mountain area, feedback may be limited to the needs of this geographic region.

Conclusions

A trauma-informed training was developed for VTCs to facilitate relevant understanding of justice-involved veterans’ needs and presentations in court, introduce skills to address challenges that arise (eg, motivation, emotional dysregulation), and provide interdisciplinary support to court professionals. This training was an important step toward fostering strong collaborations between VHA HCPs and community-based veterans courts, and feedback received during development and following implementation highlighted the perceived need for a skills-based approach to such trainings. Further program development and evaluation can strengthen this training and provide a foundation for dissemination to a broader scope of VTCs, with the goal of reducing recidivism risk among justice-involved veterans by promoting effective engagement in problem-solving court.

Despite the success of several US Department of Veterans Affairs (VA) initiatives in facilitating psychosocial functioning, rehabilitation, and re-entry among veterans experiencing homelessness and/or interactions with the criminal justice system (ie, justice-involved veterans), suicide risk among these veterans remains a significant public health concern. Rates of suicide among veterans experiencing homelessness are more than double that of veterans with no history of homelessness.¹ Similarly, justice-involved veterans experience myriad mental health concerns, including elevated rates of psychiatric symptoms, suicidal thoughts, and self-directed violence relative to those with no history of criminal justice involvement.²

In addition, a bidirectional relationship between criminal justice involvement and homelessness, often called the “institutional circuit,” is well established. Criminal justice involvement can directly result in difficulty finding housing.³ For example, veterans may have their lease agreement denied based solely on their history of criminogenic behavior. Moreover, criminal justice involvement can indirectly impact a veteran’s ability to maintain housing. Indeed, justice-involved veterans can experience difficulty attaining and sustaining employment, which in turn can result in financial difficulties, including inability to afford rental or mortgage payments.

Similarly, those at risk for or experiencing housing instability may resort to criminogenic behavior to survive in the context of limited psychosocial resources.^4-6 For instance, a veteran experiencing homelessness may seek refuge from inclement weather in a heated apartment stairwell and subsequently be charged with trespassing. Similarly, these veterans also may resort to theft to eat or pay bills. To this end, homelessness and justice involvement are likely a deleterious cycle that is difficult for the veteran to escape.

Unfortunately, the concurrent impact of housing insecurity and criminal justice involvement often serves to further exacerbate mental health sequelae, including suicide risk (Figure).⁷ In addition to precipitating frustration and helplessness among veterans who are navigating these stressors, these social determinants of health can engender a perception that the veteran is a burden to those in their support system. For example, these veterans may depend on friends or family to procure housing or transportation assistance for a job, medical appointments, and court hearings.

Despite the success of several US Department of Veterans Affairs (VA) initiatives in facilitating psychosocial functioning, rehabilitation, and re-entry among veterans experiencing homelessness and/or interactions with the criminal justice system (ie, justice-involved veterans), suicide risk among these veterans remains a significant public health concern. Rates of suicide among veterans experiencing homelessness are more than double that of veterans with no history of homelessness.¹ Similarly, justice-involved veterans experience myriad mental health concerns, including elevated rates of psychiatric symptoms, suicidal thoughts, and self-directed violence relative to those with no history of criminal justice involvement.²

In addition, a bidirectional relationship between criminal justice involvement and homelessness, often called the “institutional circuit,” is well established. Criminal justice involvement can directly result in difficulty finding housing.³ For example, veterans may have their lease agreement denied based solely on their history of criminogenic behavior. Moreover, criminal justice involvement can indirectly impact a veteran’s ability to maintain housing. Indeed, justice-involved veterans can experience difficulty attaining and sustaining employment, which in turn can result in financial difficulties, including inability to afford rental or mortgage payments.

Similarly, those at risk for or experiencing housing instability may resort to criminogenic behavior to survive in the context of limited psychosocial resources.^4-6 For instance, a veteran experiencing homelessness may seek refuge from inclement weather in a heated apartment stairwell and subsequently be charged with trespassing. Similarly, these veterans also may resort to theft to eat or pay bills. To this end, homelessness and justice involvement are likely a deleterious cycle that is difficult for the veteran to escape.

Unfortunately, the concurrent impact of housing insecurity and criminal justice involvement often serves to further exacerbate mental health sequelae, including suicide risk (Figure).⁷ In addition to precipitating frustration and helplessness among veterans who are navigating these stressors, these social determinants of health can engender a perception that the veteran is a burden to those in their support system. For example, these veterans may depend on friends or family to procure housing or transportation assistance for a job, medical appointments, and court hearings.

Despite the success of several US Department of Veterans Affairs (VA) initiatives in facilitating psychosocial functioning, rehabilitation, and re-entry among veterans experiencing homelessness and/or interactions with the criminal justice system (ie, justice-involved veterans), suicide risk among these veterans remains a significant public health concern. Rates of suicide among veterans experiencing homelessness are more than double that of veterans with no history of homelessness.¹ Similarly, justice-involved veterans experience myriad mental health concerns, including elevated rates of psychiatric symptoms, suicidal thoughts, and self-directed violence relative to those with no history of criminal justice involvement.²

In addition, a bidirectional relationship between criminal justice involvement and homelessness, often called the “institutional circuit,” is well established. Criminal justice involvement can directly result in difficulty finding housing.³ For example, veterans may have their lease agreement denied based solely on their history of criminogenic behavior. Moreover, criminal justice involvement can indirectly impact a veteran’s ability to maintain housing. Indeed, justice-involved veterans can experience difficulty attaining and sustaining employment, which in turn can result in financial difficulties, including inability to afford rental or mortgage payments.

Similarly, those at risk for or experiencing housing instability may resort to criminogenic behavior to survive in the context of limited psychosocial resources.^4-6 For instance, a veteran experiencing homelessness may seek refuge from inclement weather in a heated apartment stairwell and subsequently be charged with trespassing. Similarly, these veterans also may resort to theft to eat or pay bills. To this end, homelessness and justice involvement are likely a deleterious cycle that is difficult for the veteran to escape.

Unfortunately, the concurrent impact of housing insecurity and criminal justice involvement often serves to further exacerbate mental health sequelae, including suicide risk (Figure).⁷ In addition to precipitating frustration and helplessness among veterans who are navigating these stressors, these social determinants of health can engender a perception that the veteran is a burden to those in their support system. For example, these veterans may depend on friends or family to procure housing or transportation assistance for a job, medical appointments, and court hearings.

Although about 8.3% of the general adult civilian population will be diagnosed with posttraumatic stress disorder (PTSD) in their lifetime, rates of PTSD are even higher in the veteran population.^1,2 PTSD is associated with a number of psychosocial consequences in veterans, including decreased intimate partner relationship functioning.^3,4 For example, Cloitre and colleagues reported that PTSD is associated with difficulty with socializing, intimacy, responsibility, and control, all of which increase difficulties in intimate partner relationships.⁵ Similarly, researchers also have noted that traumatic experiences can affect an individual’s attachment style, resulting in progressive avoidance of interpersonal relationships, which can lead to marked difficulties in maintaining and beginning intimate partner relationships.^6,7 Despite these known consequences of PTSD, as Dekel and Monson noted in a review,further research is still needed regarding the mechanisms by which trauma and PTSD result in decreased intimate partner relationship functioning among veterans.⁸ Nonetheless, as positive interpersonal relationships are associated with decreased PTSD symptom severity^9,10 and increased engagement in PTSD treatment,¹¹ determining methods of measuring intimate partner relationship functioning in veterans with PTSD is important to inform future research and aid the provision of care.

To date, limited research has examined the valid measurement of intimate partner relationship functioning among veterans with PTSD. Many existing measures that comprehensively assess intimate partner relationship functioning are time and resource intensive. One such measure, the Timberlawn Couple and Family Evaluation Scales (TCFES), comprehensively assesses multiple pertinent domains of intimate partner relationship functioning (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict).¹² By assessing multiple domains, the TCFES offers a method of understanding the specific components of an individual’s intimate partner relationship in need of increased clinical attention.¹² However, the TCFES is a time- and labor-intensive observational measure that requires a couple to interact while a blinded, independent rater observes and rates their interactions using an intricate coding process. This survey structure precludes the ability to quickly and comprehensively assess a veteran’s intimate partner functioning in settings such as mental health outpatient clinics where mental health providers engage in brief, time-limited psychotherapy. As such, brief measures of intimate partner relationship functioning are needed to best inform clinical care among veterans with PTSD.

The primary aim of the current study was to create a psychometrically valid, yet brief, self-report version of the TCFES to assess multiple domains of intimate partner relationship functioning. The psychometric properties of this measure were assessed among a sample of US veterans with PTSD who were in an intimate partner relationship. We specifically examined factor structure, reliability, and associations to established measures of specific domains of relational functioning.

Methods

Ninety-four veterans were recruited via posted advertisements, promotion in PTSD therapy groups/staff meetings, and word of mouth at the Dallas Veterans Affairs Medical Center (VAMC). Participants were eligible if they had a documented diagnosis of PTSD as confirmed in the veteran’s electronic medical record and an affirmative response to currently being involved in an intimate partner relationship (ie, legally married, common-law spouse, involved in a relationship/partnership). There were no exclusion criteria.

Interested veterans were invited to complete several study-related self-report measures concerning their intimate partner relationships that would take about an hour. They were informed that the surveys were voluntary and confidential, and that they would be compensated for their participation. All veterans who participated provided written consent and the study was approved by the Dallas VAMC institutional review board.

Of the 94 veterans recruited, 3 veterans’ data were removed from current analyses after informed consent but before completing the surveys when they indicated they were not currently in a relationship or were divorced. After consent, the 91 participants were administered several study-related self-report measures. The measures took between 30 and 55 minutes to complete. Participants were then compensated $25 for their participation.

Intimate Partner Relationship Functioning

The 16-item TCFES self-report version (TCFES-SR) was developed to assess multiple domains of interpersonal functioning (Appendix). The observational TCFES assesses 5 intimate partner relationship characteristic domains (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict) during a couple’s interaction by an independent trained rater.¹² Each of the 16 TCFES-SR items were modeled after original constructs measured by the TCFES, including power, closeness, clarify, other’s views, responsibility, closure, negotiation, expressiveness, responsiveness, positive regard, negative regard, mood/tone, empathy, frequency, affective quality, and generalization and escalation. To maintain consistency with the TCFES, each item of the TCFES-SR was scored from 1 (severely dysfunctional) to 5 (highly functional). Additionally, all item wording for the TCFES-SR was based on wording in the TCFES manual after consultation with an expert who facilitated the development of the TCFES.¹² On average, the TCFES-SR took 5 to 10 minutes to complete.

To measure concurrent validity of the modified TCFES-SR, several additional interpersonal measures were selected and administered based on prior research and established domains of the TCFES. The Positive and Negative Quality in Marriage Scale (PANQIMS) was administered to assess perceived attitudes toward a relationship.^13,14 The PANQIMS generates 2 subscales: positive quality and negative quality in the relationship. Because the PANQIMS specifically assesses married relationships and our sample included married and nonmarried participants, wording was modified (eg, “spouse/partner”).

The relative power subscale of the Network Relationships Inventory–Relationship Qualities Version (NRI-RQV) measure was administered to assess the unequal/shared role romantic partners have in power equality (ie, relative power).¹⁵

The Revised Dyadic Adjustment Scale (RDAS) is a self-report measure that assesses multiple dimensions of marital adjustment and functioning.¹⁶ Six subscales of the RDAS were chosen based on items of the TCFES-SR: decision making, values, affection, conflict, activities, and discussion.

The Interpersonal Reactivity Index (IRI) empathetic concern subscale was administered to assess empathy across multiple contexts and situations¹⁷ and the Experiences in Close Relationships-Revised Questionnaire (ECR-R) was administered to assess relational functioning by determining attachment-related anxiety and avoidance.¹⁸

Sociodemographic Information

A sociodemographic questionnaire also was administered. The questionnaire assessed gender, age, education, service branch, length of interpersonal relationship, race, and ethnicity of the veteran as well as gender of the veteran’s partner.

Statistical Analysis

Factor structure of the TCFES-SR was determined by conducting an exploratory factor analysis. To allow for correlation between items, the Promax oblique rotation method was chosen.¹⁹ Number of factors was determined by agreement between number of eigenvalues ≥ 1, visual inspection of the scree plot, and a parallel analysis. Factor loadings of ≥ 0.3 were used to determine which items loaded on to which factors.

Convergent validity was assessed by conducting Pearson’s bivariate correlations between identified TCFES-SR factor(s) and other administered measures of interpersonal functioning (ie, PANQIMS positive and negative quality; NRI-RQV relative power subscale; RDAS decision making, values, affection, conflict, activities, and discussion subscales; IRI-empathetic concern subscale; and ECR-R attachment-related anxiety and avoidance subscales). Strength of relationship was determined based on the following guidelines: ± 0.3 to 0.49 = small, ± 0.5 to 0.69 = moderate, and ± 0.7 to 1.00 = large. Internal consistency was also determined for TCFES-SR factor(s) using Cronbach’s α. A standard level of significance (α=.05) was used for all statistical analyses.

Results

Eighty-six veterans provided complete data (Table 1). The Kaiser-Meyer-Olkin measure of sampling adequacy was indicative that sample size was adequate (.91), while Bartlett’s test of sphericity found the variables were suitable for structure detection, χ² (120) = 800.00, P < .001. While 2 eigenvalues were ≥ 1, visual inspection of the scree plot and subsequent parallel analysis identified a unidimensional structure (ie, 1 factor) for the TCFES-SR. All items were found to load to this single factor, with all loadings being ≥ 0.5 (Table 2). Additionally, internal consistency was excellent for the scale (α = .93).

Pearson’s bivariate correlations were significant (P < .05) between TCFES-SR total score, and almost all administered interpersonal functioning measures (Table 3). Interestingly, no significant associations were found between any of the administered measures, including the TCFES-SR total score, and the IRI-empathetic concern subscale (P > .05).

Discussion

These findings provide initial support for the psychometric properties of the TCFES-SR, including excellent internal consistency and the adequate association of its total score to established measures of interpersonal functioning. Contrary to the TCFES, the TCFES-SR was shown to best fit a unidimensional factor rather than a multidimensional measure of relationship functioning. However, the TCFES-SR was also shown to have strong convergent validity with multiple domains of relationship functioning, indicating that the measure of overall intimate partner relationship functioning encompasses a number of relational domains (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict). Critically, the TCFES-SR is brief and was administered easily in our sample, providing utility as clinical tool to be used in time-sensitive outpatient settings.

A unidimensional factor has particular strength in providing a global portrait of perceived intimate partner relationship functioning, and mental health providers can administer the TCFES-SR to assess for overall perceptions of intimate partner relationship functioning rather than administering a number of measures focusing on specific interpersonal domains (eg, decision making processes or positive/negative attitudes towards one’s relationship). This allows for the quick assessment (ie, 5-10 minutes) of overall intimate partner relationship functioning rather than administration of multiple self-report measures which can be time-intensive and expensive. However, the TCFES-SR also is limited by a lack of nuanced understanding of perceptions of functioning specific to particular domains. For example, the TCFES-SR score cannot describe intimate partner functioning in the domain of problem solving. Therefore, brief screening tools need to be developed that assess multiple intimate partner relationship domains.

Importantly, overall intimate partner relationship functioning as measured by the TCFES-SR may not incorporate perceptions of relationship empathy, as the total score did not correlate with a measure of empathetic concern (ie, the IRI-empathetic concern subscale). As empathy was based on one item in the TCFES-SR vs 7 in the IRI-empathetic concern subscale, it is unclear if the TCFES-SR only captures a portion of the construct of empathy (ie, sensitivity to partner) vs the comprehensive assessment of trait empathy that the IRI subscale measures. Additionally, the IRI-empathetic concern subscale did not significantly correlate with any of the other administered measures of relationship functioning. Given the role of empathy in positive, healthy intimate partner relationships, future research should explore the role of empathetic concern among veterans with PTSD as it relates to overall (eg, TCFES-SR) and specific aspects of intimate partner relationship functioning.²⁰

While the clinical applicability of the TCFES-SR requires further examination, this measure has a number of potential uses. Information captured quickly by the TCFES-SR may help to inform appropriate referral for treatment. For instance, veterans reporting low total scores on the TCFES-SR may indicate a need for a referral for intervention focused on improving overall relationship functioning (eg, Integrative Behavioral Couple Therapy).^21,22 Measurement-based care (ie, tracking and discussing changes in symptoms during treatment using validated self-report measures) is now required by the Joint Commission as a standard of care,and has been shown to improve outcomes in couples therapy.^23,24 As a brief self-report measure, the TCFES-SR may be able to facilitate measurement-based care and assist providers in tracking changes in overall relationship functioning over the course of treatment. However, the purpose of the current study was to validate the TCFES-SR and not to examine the utility of the TCFES-SR in clinical care; additional research is needed to determine standardized cutoff scores to indicate a need for clinical intervention.

Limitations

Several limitations should be noted. The current study only assessed perceived intimate partner relationship functioning from the perspective of the veteran, thus limiting implications as it pertains to the spouse/partner of the veteran. PTSD diagnosis was based on chart review rather than a psychodiagnostic measure (eg, Clinician Administered PTSD Scale); therefore, whether this diagnosis was current or in remission was unclear. Although our sample was adequate to conduct an exploratory factor analysis,the overall sample size was modest, and results should be considered preliminary with need for further replication.²⁵ The sample was also primarily male, white or black, and non-Hispanic; therefore, results may not generalize to a more sociodemographically diverse population. Finally, given the focus of the study to develop a self-report measure, we did not compare the TCFES-SR to the original TCFES. Thus, further research examining the relationship between the TCFES-SR and TCFES may be needed to better understand overlap and potential incongruence in these measures, and to ascertain any differences in their factor structures.

Conclusion

This study is novel in that it adapted a comprehensive observational measure of relationship functioning to a self-report measure piloted among a sample of veterans with PTSD in an intimate partner relationship, a clinical population that remains largely understudied. Although findings are preliminary, the TCFES-SR was found to be a reliable and valid measure of overall intimate partner relationship functioning. Given the rapid administration of this self-report measure, the TCFES-SR may hold clinical utility as a screen of intimate partner relationship deficits in need of clinical intervention. Replication in a larger, more diverse sample is needed to further examine the generalizability and confirm psychometric properties of the TCFES-SR. Additionally, further understanding of the clinical utility of the TCFES-SR in treatment settings remains critical to promote the development and maintenance of healthy intimate partner relationships among veterans with PTSD. Finally, development of effective self-report measures of intimate partner relationship functioning, such as the TCFES-SR, may help to facilitate needed research to understand the effect of PTSD on establishing and maintaining healthy intimate partner relationships among veterans.

Acknowledgments

The current study was funded by the Timberlawn Psychiatric Research Foundation. This material is the result of work supported in part by the US Department of Veterans Affairs; the Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention; Sierra Pacific MIRECC; and the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs.

Although about 8.3% of the general adult civilian population will be diagnosed with posttraumatic stress disorder (PTSD) in their lifetime, rates of PTSD are even higher in the veteran population.^1,2 PTSD is associated with a number of psychosocial consequences in veterans, including decreased intimate partner relationship functioning.^3,4 For example, Cloitre and colleagues reported that PTSD is associated with difficulty with socializing, intimacy, responsibility, and control, all of which increase difficulties in intimate partner relationships.⁵ Similarly, researchers also have noted that traumatic experiences can affect an individual’s attachment style, resulting in progressive avoidance of interpersonal relationships, which can lead to marked difficulties in maintaining and beginning intimate partner relationships.^6,7 Despite these known consequences of PTSD, as Dekel and Monson noted in a review,further research is still needed regarding the mechanisms by which trauma and PTSD result in decreased intimate partner relationship functioning among veterans.⁸ Nonetheless, as positive interpersonal relationships are associated with decreased PTSD symptom severity^9,10 and increased engagement in PTSD treatment,¹¹ determining methods of measuring intimate partner relationship functioning in veterans with PTSD is important to inform future research and aid the provision of care.

To date, limited research has examined the valid measurement of intimate partner relationship functioning among veterans with PTSD. Many existing measures that comprehensively assess intimate partner relationship functioning are time and resource intensive. One such measure, the Timberlawn Couple and Family Evaluation Scales (TCFES), comprehensively assesses multiple pertinent domains of intimate partner relationship functioning (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict).¹² By assessing multiple domains, the TCFES offers a method of understanding the specific components of an individual’s intimate partner relationship in need of increased clinical attention.¹² However, the TCFES is a time- and labor-intensive observational measure that requires a couple to interact while a blinded, independent rater observes and rates their interactions using an intricate coding process. This survey structure precludes the ability to quickly and comprehensively assess a veteran’s intimate partner functioning in settings such as mental health outpatient clinics where mental health providers engage in brief, time-limited psychotherapy. As such, brief measures of intimate partner relationship functioning are needed to best inform clinical care among veterans with PTSD.

The primary aim of the current study was to create a psychometrically valid, yet brief, self-report version of the TCFES to assess multiple domains of intimate partner relationship functioning. The psychometric properties of this measure were assessed among a sample of US veterans with PTSD who were in an intimate partner relationship. We specifically examined factor structure, reliability, and associations to established measures of specific domains of relational functioning.

Methods

Ninety-four veterans were recruited via posted advertisements, promotion in PTSD therapy groups/staff meetings, and word of mouth at the Dallas Veterans Affairs Medical Center (VAMC). Participants were eligible if they had a documented diagnosis of PTSD as confirmed in the veteran’s electronic medical record and an affirmative response to currently being involved in an intimate partner relationship (ie, legally married, common-law spouse, involved in a relationship/partnership). There were no exclusion criteria.

Interested veterans were invited to complete several study-related self-report measures concerning their intimate partner relationships that would take about an hour. They were informed that the surveys were voluntary and confidential, and that they would be compensated for their participation. All veterans who participated provided written consent and the study was approved by the Dallas VAMC institutional review board.

Of the 94 veterans recruited, 3 veterans’ data were removed from current analyses after informed consent but before completing the surveys when they indicated they were not currently in a relationship or were divorced. After consent, the 91 participants were administered several study-related self-report measures. The measures took between 30 and 55 minutes to complete. Participants were then compensated $25 for their participation.

Intimate Partner Relationship Functioning

The 16-item TCFES self-report version (TCFES-SR) was developed to assess multiple domains of interpersonal functioning (Appendix). The observational TCFES assesses 5 intimate partner relationship characteristic domains (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict) during a couple’s interaction by an independent trained rater.¹² Each of the 16 TCFES-SR items were modeled after original constructs measured by the TCFES, including power, closeness, clarify, other’s views, responsibility, closure, negotiation, expressiveness, responsiveness, positive regard, negative regard, mood/tone, empathy, frequency, affective quality, and generalization and escalation. To maintain consistency with the TCFES, each item of the TCFES-SR was scored from 1 (severely dysfunctional) to 5 (highly functional). Additionally, all item wording for the TCFES-SR was based on wording in the TCFES manual after consultation with an expert who facilitated the development of the TCFES.¹² On average, the TCFES-SR took 5 to 10 minutes to complete.

To measure concurrent validity of the modified TCFES-SR, several additional interpersonal measures were selected and administered based on prior research and established domains of the TCFES. The Positive and Negative Quality in Marriage Scale (PANQIMS) was administered to assess perceived attitudes toward a relationship.^13,14 The PANQIMS generates 2 subscales: positive quality and negative quality in the relationship. Because the PANQIMS specifically assesses married relationships and our sample included married and nonmarried participants, wording was modified (eg, “spouse/partner”).

The relative power subscale of the Network Relationships Inventory–Relationship Qualities Version (NRI-RQV) measure was administered to assess the unequal/shared role romantic partners have in power equality (ie, relative power).¹⁵

The Revised Dyadic Adjustment Scale (RDAS) is a self-report measure that assesses multiple dimensions of marital adjustment and functioning.¹⁶ Six subscales of the RDAS were chosen based on items of the TCFES-SR: decision making, values, affection, conflict, activities, and discussion.

The Interpersonal Reactivity Index (IRI) empathetic concern subscale was administered to assess empathy across multiple contexts and situations¹⁷ and the Experiences in Close Relationships-Revised Questionnaire (ECR-R) was administered to assess relational functioning by determining attachment-related anxiety and avoidance.¹⁸

Sociodemographic Information

A sociodemographic questionnaire also was administered. The questionnaire assessed gender, age, education, service branch, length of interpersonal relationship, race, and ethnicity of the veteran as well as gender of the veteran’s partner.

Statistical Analysis

Factor structure of the TCFES-SR was determined by conducting an exploratory factor analysis. To allow for correlation between items, the Promax oblique rotation method was chosen.¹⁹ Number of factors was determined by agreement between number of eigenvalues ≥ 1, visual inspection of the scree plot, and a parallel analysis. Factor loadings of ≥ 0.3 were used to determine which items loaded on to which factors.

Convergent validity was assessed by conducting Pearson’s bivariate correlations between identified TCFES-SR factor(s) and other administered measures of interpersonal functioning (ie, PANQIMS positive and negative quality; NRI-RQV relative power subscale; RDAS decision making, values, affection, conflict, activities, and discussion subscales; IRI-empathetic concern subscale; and ECR-R attachment-related anxiety and avoidance subscales). Strength of relationship was determined based on the following guidelines: ± 0.3 to 0.49 = small, ± 0.5 to 0.69 = moderate, and ± 0.7 to 1.00 = large. Internal consistency was also determined for TCFES-SR factor(s) using Cronbach’s α. A standard level of significance (α=.05) was used for all statistical analyses.

Results

Eighty-six veterans provided complete data (Table 1). The Kaiser-Meyer-Olkin measure of sampling adequacy was indicative that sample size was adequate (.91), while Bartlett’s test of sphericity found the variables were suitable for structure detection, χ² (120) = 800.00, P < .001. While 2 eigenvalues were ≥ 1, visual inspection of the scree plot and subsequent parallel analysis identified a unidimensional structure (ie, 1 factor) for the TCFES-SR. All items were found to load to this single factor, with all loadings being ≥ 0.5 (Table 2). Additionally, internal consistency was excellent for the scale (α = .93).

Pearson’s bivariate correlations were significant (P < .05) between TCFES-SR total score, and almost all administered interpersonal functioning measures (Table 3). Interestingly, no significant associations were found between any of the administered measures, including the TCFES-SR total score, and the IRI-empathetic concern subscale (P > .05).

Discussion

These findings provide initial support for the psychometric properties of the TCFES-SR, including excellent internal consistency and the adequate association of its total score to established measures of interpersonal functioning. Contrary to the TCFES, the TCFES-SR was shown to best fit a unidimensional factor rather than a multidimensional measure of relationship functioning. However, the TCFES-SR was also shown to have strong convergent validity with multiple domains of relationship functioning, indicating that the measure of overall intimate partner relationship functioning encompasses a number of relational domains (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict). Critically, the TCFES-SR is brief and was administered easily in our sample, providing utility as clinical tool to be used in time-sensitive outpatient settings.

A unidimensional factor has particular strength in providing a global portrait of perceived intimate partner relationship functioning, and mental health providers can administer the TCFES-SR to assess for overall perceptions of intimate partner relationship functioning rather than administering a number of measures focusing on specific interpersonal domains (eg, decision making processes or positive/negative attitudes towards one’s relationship). This allows for the quick assessment (ie, 5-10 minutes) of overall intimate partner relationship functioning rather than administration of multiple self-report measures which can be time-intensive and expensive. However, the TCFES-SR also is limited by a lack of nuanced understanding of perceptions of functioning specific to particular domains. For example, the TCFES-SR score cannot describe intimate partner functioning in the domain of problem solving. Therefore, brief screening tools need to be developed that assess multiple intimate partner relationship domains.

Importantly, overall intimate partner relationship functioning as measured by the TCFES-SR may not incorporate perceptions of relationship empathy, as the total score did not correlate with a measure of empathetic concern (ie, the IRI-empathetic concern subscale). As empathy was based on one item in the TCFES-SR vs 7 in the IRI-empathetic concern subscale, it is unclear if the TCFES-SR only captures a portion of the construct of empathy (ie, sensitivity to partner) vs the comprehensive assessment of trait empathy that the IRI subscale measures. Additionally, the IRI-empathetic concern subscale did not significantly correlate with any of the other administered measures of relationship functioning. Given the role of empathy in positive, healthy intimate partner relationships, future research should explore the role of empathetic concern among veterans with PTSD as it relates to overall (eg, TCFES-SR) and specific aspects of intimate partner relationship functioning.²⁰

While the clinical applicability of the TCFES-SR requires further examination, this measure has a number of potential uses. Information captured quickly by the TCFES-SR may help to inform appropriate referral for treatment. For instance, veterans reporting low total scores on the TCFES-SR may indicate a need for a referral for intervention focused on improving overall relationship functioning (eg, Integrative Behavioral Couple Therapy).^21,22 Measurement-based care (ie, tracking and discussing changes in symptoms during treatment using validated self-report measures) is now required by the Joint Commission as a standard of care,and has been shown to improve outcomes in couples therapy.^23,24 As a brief self-report measure, the TCFES-SR may be able to facilitate measurement-based care and assist providers in tracking changes in overall relationship functioning over the course of treatment. However, the purpose of the current study was to validate the TCFES-SR and not to examine the utility of the TCFES-SR in clinical care; additional research is needed to determine standardized cutoff scores to indicate a need for clinical intervention.

Limitations

Several limitations should be noted. The current study only assessed perceived intimate partner relationship functioning from the perspective of the veteran, thus limiting implications as it pertains to the spouse/partner of the veteran. PTSD diagnosis was based on chart review rather than a psychodiagnostic measure (eg, Clinician Administered PTSD Scale); therefore, whether this diagnosis was current or in remission was unclear. Although our sample was adequate to conduct an exploratory factor analysis,the overall sample size was modest, and results should be considered preliminary with need for further replication.²⁵ The sample was also primarily male, white or black, and non-Hispanic; therefore, results may not generalize to a more sociodemographically diverse population. Finally, given the focus of the study to develop a self-report measure, we did not compare the TCFES-SR to the original TCFES. Thus, further research examining the relationship between the TCFES-SR and TCFES may be needed to better understand overlap and potential incongruence in these measures, and to ascertain any differences in their factor structures.

Conclusion

This study is novel in that it adapted a comprehensive observational measure of relationship functioning to a self-report measure piloted among a sample of veterans with PTSD in an intimate partner relationship, a clinical population that remains largely understudied. Although findings are preliminary, the TCFES-SR was found to be a reliable and valid measure of overall intimate partner relationship functioning. Given the rapid administration of this self-report measure, the TCFES-SR may hold clinical utility as a screen of intimate partner relationship deficits in need of clinical intervention. Replication in a larger, more diverse sample is needed to further examine the generalizability and confirm psychometric properties of the TCFES-SR. Additionally, further understanding of the clinical utility of the TCFES-SR in treatment settings remains critical to promote the development and maintenance of healthy intimate partner relationships among veterans with PTSD. Finally, development of effective self-report measures of intimate partner relationship functioning, such as the TCFES-SR, may help to facilitate needed research to understand the effect of PTSD on establishing and maintaining healthy intimate partner relationships among veterans.

Acknowledgments

The current study was funded by the Timberlawn Psychiatric Research Foundation. This material is the result of work supported in part by the US Department of Veterans Affairs; the Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention; Sierra Pacific MIRECC; and the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs.

Although about 8.3% of the general adult civilian population will be diagnosed with posttraumatic stress disorder (PTSD) in their lifetime, rates of PTSD are even higher in the veteran population.^1,2 PTSD is associated with a number of psychosocial consequences in veterans, including decreased intimate partner relationship functioning.^3,4 For example, Cloitre and colleagues reported that PTSD is associated with difficulty with socializing, intimacy, responsibility, and control, all of which increase difficulties in intimate partner relationships.⁵ Similarly, researchers also have noted that traumatic experiences can affect an individual’s attachment style, resulting in progressive avoidance of interpersonal relationships, which can lead to marked difficulties in maintaining and beginning intimate partner relationships.^6,7 Despite these known consequences of PTSD, as Dekel and Monson noted in a review,further research is still needed regarding the mechanisms by which trauma and PTSD result in decreased intimate partner relationship functioning among veterans.⁸ Nonetheless, as positive interpersonal relationships are associated with decreased PTSD symptom severity^9,10 and increased engagement in PTSD treatment,¹¹ determining methods of measuring intimate partner relationship functioning in veterans with PTSD is important to inform future research and aid the provision of care.

To date, limited research has examined the valid measurement of intimate partner relationship functioning among veterans with PTSD. Many existing measures that comprehensively assess intimate partner relationship functioning are time and resource intensive. One such measure, the Timberlawn Couple and Family Evaluation Scales (TCFES), comprehensively assesses multiple pertinent domains of intimate partner relationship functioning (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict).¹² By assessing multiple domains, the TCFES offers a method of understanding the specific components of an individual’s intimate partner relationship in need of increased clinical attention.¹² However, the TCFES is a time- and labor-intensive observational measure that requires a couple to interact while a blinded, independent rater observes and rates their interactions using an intricate coding process. This survey structure precludes the ability to quickly and comprehensively assess a veteran’s intimate partner functioning in settings such as mental health outpatient clinics where mental health providers engage in brief, time-limited psychotherapy. As such, brief measures of intimate partner relationship functioning are needed to best inform clinical care among veterans with PTSD.

The primary aim of the current study was to create a psychometrically valid, yet brief, self-report version of the TCFES to assess multiple domains of intimate partner relationship functioning. The psychometric properties of this measure were assessed among a sample of US veterans with PTSD who were in an intimate partner relationship. We specifically examined factor structure, reliability, and associations to established measures of specific domains of relational functioning.

Methods

Ninety-four veterans were recruited via posted advertisements, promotion in PTSD therapy groups/staff meetings, and word of mouth at the Dallas Veterans Affairs Medical Center (VAMC). Participants were eligible if they had a documented diagnosis of PTSD as confirmed in the veteran’s electronic medical record and an affirmative response to currently being involved in an intimate partner relationship (ie, legally married, common-law spouse, involved in a relationship/partnership). There were no exclusion criteria.

Interested veterans were invited to complete several study-related self-report measures concerning their intimate partner relationships that would take about an hour. They were informed that the surveys were voluntary and confidential, and that they would be compensated for their participation. All veterans who participated provided written consent and the study was approved by the Dallas VAMC institutional review board.

Of the 94 veterans recruited, 3 veterans’ data were removed from current analyses after informed consent but before completing the surveys when they indicated they were not currently in a relationship or were divorced. After consent, the 91 participants were administered several study-related self-report measures. The measures took between 30 and 55 minutes to complete. Participants were then compensated $25 for their participation.

Intimate Partner Relationship Functioning

The 16-item TCFES self-report version (TCFES-SR) was developed to assess multiple domains of interpersonal functioning (Appendix). The observational TCFES assesses 5 intimate partner relationship characteristic domains (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict) during a couple’s interaction by an independent trained rater.¹² Each of the 16 TCFES-SR items were modeled after original constructs measured by the TCFES, including power, closeness, clarify, other’s views, responsibility, closure, negotiation, expressiveness, responsiveness, positive regard, negative regard, mood/tone, empathy, frequency, affective quality, and generalization and escalation. To maintain consistency with the TCFES, each item of the TCFES-SR was scored from 1 (severely dysfunctional) to 5 (highly functional). Additionally, all item wording for the TCFES-SR was based on wording in the TCFES manual after consultation with an expert who facilitated the development of the TCFES.¹² On average, the TCFES-SR took 5 to 10 minutes to complete.

To measure concurrent validity of the modified TCFES-SR, several additional interpersonal measures were selected and administered based on prior research and established domains of the TCFES. The Positive and Negative Quality in Marriage Scale (PANQIMS) was administered to assess perceived attitudes toward a relationship.^13,14 The PANQIMS generates 2 subscales: positive quality and negative quality in the relationship. Because the PANQIMS specifically assesses married relationships and our sample included married and nonmarried participants, wording was modified (eg, “spouse/partner”).

The relative power subscale of the Network Relationships Inventory–Relationship Qualities Version (NRI-RQV) measure was administered to assess the unequal/shared role romantic partners have in power equality (ie, relative power).¹⁵

The Revised Dyadic Adjustment Scale (RDAS) is a self-report measure that assesses multiple dimensions of marital adjustment and functioning.¹⁶ Six subscales of the RDAS were chosen based on items of the TCFES-SR: decision making, values, affection, conflict, activities, and discussion.

The Interpersonal Reactivity Index (IRI) empathetic concern subscale was administered to assess empathy across multiple contexts and situations¹⁷ and the Experiences in Close Relationships-Revised Questionnaire (ECR-R) was administered to assess relational functioning by determining attachment-related anxiety and avoidance.¹⁸

Sociodemographic Information

A sociodemographic questionnaire also was administered. The questionnaire assessed gender, age, education, service branch, length of interpersonal relationship, race, and ethnicity of the veteran as well as gender of the veteran’s partner.

Statistical Analysis

Factor structure of the TCFES-SR was determined by conducting an exploratory factor analysis. To allow for correlation between items, the Promax oblique rotation method was chosen.¹⁹ Number of factors was determined by agreement between number of eigenvalues ≥ 1, visual inspection of the scree plot, and a parallel analysis. Factor loadings of ≥ 0.3 were used to determine which items loaded on to which factors.

Convergent validity was assessed by conducting Pearson’s bivariate correlations between identified TCFES-SR factor(s) and other administered measures of interpersonal functioning (ie, PANQIMS positive and negative quality; NRI-RQV relative power subscale; RDAS decision making, values, affection, conflict, activities, and discussion subscales; IRI-empathetic concern subscale; and ECR-R attachment-related anxiety and avoidance subscales). Strength of relationship was determined based on the following guidelines: ± 0.3 to 0.49 = small, ± 0.5 to 0.69 = moderate, and ± 0.7 to 1.00 = large. Internal consistency was also determined for TCFES-SR factor(s) using Cronbach’s α. A standard level of significance (α=.05) was used for all statistical analyses.

Results

Eighty-six veterans provided complete data (Table 1). The Kaiser-Meyer-Olkin measure of sampling adequacy was indicative that sample size was adequate (.91), while Bartlett’s test of sphericity found the variables were suitable for structure detection, χ² (120) = 800.00, P < .001. While 2 eigenvalues were ≥ 1, visual inspection of the scree plot and subsequent parallel analysis identified a unidimensional structure (ie, 1 factor) for the TCFES-SR. All items were found to load to this single factor, with all loadings being ≥ 0.5 (Table 2). Additionally, internal consistency was excellent for the scale (α = .93).

Pearson’s bivariate correlations were significant (P < .05) between TCFES-SR total score, and almost all administered interpersonal functioning measures (Table 3). Interestingly, no significant associations were found between any of the administered measures, including the TCFES-SR total score, and the IRI-empathetic concern subscale (P > .05).

Discussion

These findings provide initial support for the psychometric properties of the TCFES-SR, including excellent internal consistency and the adequate association of its total score to established measures of interpersonal functioning. Contrary to the TCFES, the TCFES-SR was shown to best fit a unidimensional factor rather than a multidimensional measure of relationship functioning. However, the TCFES-SR was also shown to have strong convergent validity with multiple domains of relationship functioning, indicating that the measure of overall intimate partner relationship functioning encompasses a number of relational domains (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict). Critically, the TCFES-SR is brief and was administered easily in our sample, providing utility as clinical tool to be used in time-sensitive outpatient settings.

A unidimensional factor has particular strength in providing a global portrait of perceived intimate partner relationship functioning, and mental health providers can administer the TCFES-SR to assess for overall perceptions of intimate partner relationship functioning rather than administering a number of measures focusing on specific interpersonal domains (eg, decision making processes or positive/negative attitudes towards one’s relationship). This allows for the quick assessment (ie, 5-10 minutes) of overall intimate partner relationship functioning rather than administration of multiple self-report measures which can be time-intensive and expensive. However, the TCFES-SR also is limited by a lack of nuanced understanding of perceptions of functioning specific to particular domains. For example, the TCFES-SR score cannot describe intimate partner functioning in the domain of problem solving. Therefore, brief screening tools need to be developed that assess multiple intimate partner relationship domains.

Importantly, overall intimate partner relationship functioning as measured by the TCFES-SR may not incorporate perceptions of relationship empathy, as the total score did not correlate with a measure of empathetic concern (ie, the IRI-empathetic concern subscale). As empathy was based on one item in the TCFES-SR vs 7 in the IRI-empathetic concern subscale, it is unclear if the TCFES-SR only captures a portion of the construct of empathy (ie, sensitivity to partner) vs the comprehensive assessment of trait empathy that the IRI subscale measures. Additionally, the IRI-empathetic concern subscale did not significantly correlate with any of the other administered measures of relationship functioning. Given the role of empathy in positive, healthy intimate partner relationships, future research should explore the role of empathetic concern among veterans with PTSD as it relates to overall (eg, TCFES-SR) and specific aspects of intimate partner relationship functioning.²⁰

While the clinical applicability of the TCFES-SR requires further examination, this measure has a number of potential uses. Information captured quickly by the TCFES-SR may help to inform appropriate referral for treatment. For instance, veterans reporting low total scores on the TCFES-SR may indicate a need for a referral for intervention focused on improving overall relationship functioning (eg, Integrative Behavioral Couple Therapy).^21,22 Measurement-based care (ie, tracking and discussing changes in symptoms during treatment using validated self-report measures) is now required by the Joint Commission as a standard of care,and has been shown to improve outcomes in couples therapy.^23,24 As a brief self-report measure, the TCFES-SR may be able to facilitate measurement-based care and assist providers in tracking changes in overall relationship functioning over the course of treatment. However, the purpose of the current study was to validate the TCFES-SR and not to examine the utility of the TCFES-SR in clinical care; additional research is needed to determine standardized cutoff scores to indicate a need for clinical intervention.

Limitations

Several limitations should be noted. The current study only assessed perceived intimate partner relationship functioning from the perspective of the veteran, thus limiting implications as it pertains to the spouse/partner of the veteran. PTSD diagnosis was based on chart review rather than a psychodiagnostic measure (eg, Clinician Administered PTSD Scale); therefore, whether this diagnosis was current or in remission was unclear. Although our sample was adequate to conduct an exploratory factor analysis,the overall sample size was modest, and results should be considered preliminary with need for further replication.²⁵ The sample was also primarily male, white or black, and non-Hispanic; therefore, results may not generalize to a more sociodemographically diverse population. Finally, given the focus of the study to develop a self-report measure, we did not compare the TCFES-SR to the original TCFES. Thus, further research examining the relationship between the TCFES-SR and TCFES may be needed to better understand overlap and potential incongruence in these measures, and to ascertain any differences in their factor structures.

Conclusion

This study is novel in that it adapted a comprehensive observational measure of relationship functioning to a self-report measure piloted among a sample of veterans with PTSD in an intimate partner relationship, a clinical population that remains largely understudied. Although findings are preliminary, the TCFES-SR was found to be a reliable and valid measure of overall intimate partner relationship functioning. Given the rapid administration of this self-report measure, the TCFES-SR may hold clinical utility as a screen of intimate partner relationship deficits in need of clinical intervention. Replication in a larger, more diverse sample is needed to further examine the generalizability and confirm psychometric properties of the TCFES-SR. Additionally, further understanding of the clinical utility of the TCFES-SR in treatment settings remains critical to promote the development and maintenance of healthy intimate partner relationships among veterans with PTSD. Finally, development of effective self-report measures of intimate partner relationship functioning, such as the TCFES-SR, may help to facilitate needed research to understand the effect of PTSD on establishing and maintaining healthy intimate partner relationships among veterans.

Acknowledgments

The current study was funded by the Timberlawn Psychiatric Research Foundation. This material is the result of work supported in part by the US Department of Veterans Affairs; the Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention; Sierra Pacific MIRECC; and the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs.

Increased risk of suicide among veterans with posttraumatic stress disorder (PTSD) is well established. Posttraumatic stress disorder and related consequences are associated with higher rates of suicidal ideation and suicidal self-directed violence (S-SDV).¹ Based on a systematic review, several explanations for this relationship have been hypothesized.¹ Particular emphasis has been placed on trauma type (eg, premilitary childhood abuse, combat exposure), frequency of trauma exposure (ie, a single traumatic episode vs multiple traumatic experiences), specific PTSD symptoms (eg, avoidance, sleep disturbance, alteration in mood and cognitions, risky behaviors), and other psychosocial consequences associated with PTSD (eg, low social support, psychiatric comorbidity, substance use). However, there is limited understanding regarding how to conceptualize and assess risk for suicide when treating veterans who have PTSD.

PTSD and the Interpersonal-Psychological Theory of Suicide

Although PTSD is associated with risk for S-SDV among veterans, a diagnosis-specific approach to conceptualizing risk of suicide (ie, an explanation specific to PTSD) might not be enough because most individuals with a psychiatric diagnosis do not engage in S-SDV.² Rather, theories that are able to conceptualize suicide risk across many different psychiatric diagnoses are likely to improve mental health providers’ ability to understand risk of suicide. Although many theories attempt to understand suicide risk, the Interpersonal-Psychological Theory of Suicide (IPTS) has robust empirical support.³

The IPTS proposes that suicidal ideation is driven by perceptions of stable and unchanging thwarted belongingness (TB), defined as an unmet psychological need to socially belong, and perceived burdensomeness (PB), defined as the perception that one is a burden on others.⁴ However, PB and TB are not considered sufficient for S-SDV to occur unless an individual also has acquired the capability for suicide. Capability for suicide is thought to happen when an individual loses the fear of dying by suicide and develops tolerance to physical pain, which is proposed to occur through habituation or repeated exposure to painful stimuli.³

Several studies have examined the IPTS in a number of clinical populations, including veterans and active-duty service members; yet limited research has applied the IPTS to veterans with PTSD.³ However, a recent article proposed that a number of PTSD-related factors increase risk of suicide through the lens of the IPTS.⁵ In particular, repeated exposure to painful and provocative events—especially those characterized by violence and aggression—might increase acquired capability for suicide by causing habituation to physical pain and discomfort and reducing fear of injury and death. This concept is especially concerning because of the frequent occurrence of both military- (eg, combat, military sexual trauma) and nonmilitary-related (eg, childhood abuse, intimate partner violence) stressful and traumatic events among veterans, especially individuals with PTSD.

Moreover, the acquired capability for suicide correlates highly with anxious, intrusive, and hyperarousal symptoms of PTSD.^5-7 Over time, these PTSD symptoms are thought to increase habituation to the physically painful and frightening aspects of S-SDV, resulting in increased pain tolerance and fearlessness about death.³

In addition, PTSD-related cognitive-affective states (ie, thoughts and emotions), such as guilt, shame, and self-deprecation, might drive beliefs of PB and TB.^5,8 Repeated exposure to such trauma-related thoughts and emotions could further reinforce beliefs of self-hate or inadequacy (PB).² Trauma-related beliefs that the world or others are unsafe also might reduce the likelihood of seeking social support, thereby increasing TB.² The PTSD symptoms of avoidance and self-blame also are likely to reinforce beliefs of PB and TB.²

Assessing Suicide Risk in the Context of PTSD

The IPTS framework is one that can be used by mental health providers to conceptualize risk of suicide across populations and psychiatric diagnoses, including veterans with PTSD. However, integrating additional risk assessment and management techniques is essential to guide appropriate risk stratification and treatment.

One such method of suicide risk assessment and management is therapeutic risk management (TRM).⁹ Therapeutic risk management involves a stratification process by which temporal aspects (ie, acute and chronic) and severity (ie, low, moderate, and high) of suicide risk are assessed using a combination of clinical interview and psychometrically sound self-report measures, such as the Beck Scale for Suicide Ideation, Beck Hopelessness Scale, and Reasons for Living Inventory. Appropriate clinical interventions that correspond to acute and chronic suicide risk stratification are then implemented (eg, safety planning, lethal means counseling, increasing frequency of care, hospitalization if warranted).

Therapeutic risk management emphasizes the necessity of assessing current and past suicidal ideation, intent, plan, and access to means. Moreover, additional considerations might be indicated when assessing and conceptualizing suicide risk among veterans with PTSD. Assessing lifetime trauma history, including traumas that occurred before, during, and after military service, is important for understanding whether traumatic experiences influence acute and chronic risks of suicide. As previously described, careful attention to stressful and traumatic experiences with violent and aggressive characteristics is recommended because research suggests that these experiences are associated with increased capability for suicide.⁵ Awareness of the diversity of traumatic experiences and the importance of contextual factors surrounding such experiences also are essential. For example, the nature of violence and proximity to violence (eg, directly involved in a firefight vs hearing a mortar explosion in the distance) are key components of military-related combat trauma that might differentially influence risk of suicide.¹⁰

Similarly, although military sexual trauma can include repeated threatening sexual harassment or sexual assault, research suggests that military sexual assault is particularly important for understanding suicidal ideation, and experiences of military sexual harassment are less important.¹¹ Therefore, a careful and nuanced understanding of how contextual aspects of a veteran’s trauma history might relate to his or her chronic and acute risk of suicide is critical.

Also important is considering the individual and institutional reactions to trauma. For example, veterans whose behaviors during traumatic experiences violated their values and moral code (ie, moral injury) might be at increased risk for S-SDV. Similarly, veterans who believe that the military institution did not adequately protect them from or support them in the aftermath of traumatic experience(s) (ie, institutional betrayal) might be at higher risk of suicide.

During a clinical interview, mental health providers should pay attention to beliefs and behaviors the veteran is reporting. For example, endorsement of perceptions of low social support (eg, “no one likes me”) or self-esteem (eg, “I’m just not as good as I used to be”) might be indicative of TB or PB, respectively. Additionally, providers should be aware of current or lifetime exposure to painful stimuli (eg, nonsuicidal self-injury, such as cutting or burning, previous suicide attempts) because these exposures might increase the veteran’s acquired capability of future S-SDV.

Although unstructured clinical interviews are a common suicide risk assessment approach, TRM proposes that using a thorough clinical interview along with valid self-report measures could further illuminate a patient’s risk of suicide.⁹ Implementing brief measures allows mental health providers to quickly assess several risk factors and decrease the likelihood of missing important aspects of suicide risk assessment. Providers can use a number of measures to inform their suicide risk assessment, including augmenting a clinical interview of suicide risk with a valid self-report measure of recent suicidal ideation (eg, Beck Scale for Suicide Ideation, which assesses the severity of suicidal ideation in the past week).

Additionally for veterans with PTSD, mental health providers can include measures of PTSD symptoms (eg, PTSD checklist in the Diagnostic and Statistical Manual of Mental Disorders–5) and common PTSD comorbidities (eg, Beck Depression Inventory-II for depressive symptoms) that might contribute to current risk of suicide. Based on previous research, providers also might consider adding measures of trauma-related beliefs (eg, Posttraumatic Cognitions Inventory) and emotions, such as guilt (eg, Trauma-Related Guilt Inventory).⁵

These measures could aid in identifying modifiable risk factors of suicide among veterans with PTSD, such as the extent to which certain beliefs or emotions relate to an individual’s risk of suicide. In addition to asking about characteristics of traumatic events during the clinical interview, measures of moral injury (eg, Moral Injury Events Scale) and institutional betrayal (eg, Institutional Betrayal Questionnaire) might further inform understanding of contextual aspects of trauma that could help explain an individual’s risk of suicide.

Finally, interpersonal measures also could be helpful. For example, because avoidance and social isolation are risk factors for suicidal ideation among veterans with PTSD, measures of perceived interpersonal functioning (eg, Interpersonal Needs Questionnaire) might add further data to assist in suicide risk conceptualization. Although the selection of specific measures likely varies based on the specific needs of an individual patient, these are examples of measures that can be used with veterans with PTSD to inform suicide risk assessment and conceptualization.

By combining data from various measures across multiple domains with a thorough clinical interview, mental health providers can use a TRM approach to understand and conceptualize suicide risk among veterans with PTSD. This approach can facilitate mental health providers’ ability to provide optimal care and guide intervention(s) for veterans with PTSD. One brief intervention that has been used with veterans is safety planning. During safety planning, the provider assists the veteran in identifying warning signs, internal and external coping strategies, and individuals the veteran can reach out to for help (eg, friends and family, providers, Veterans Crisis Line), in addition to collaboratively brainstorming ways the veteran can make his or her environment safer (eg, reducing access to lethal means, identifying reminders of their reasons for living).

Specific to veterans with PTSD, symptoms such as avoidance, hyperarousal, social isolation, and beliefs that others and the world are unsafe might affect safety planning. Such symptoms could hinder identification and use of coping strategies while deterring openness to reach out to others for help. A collaborative method can be used to identify alternate means of coping that take into account PTSD-related avoidance and hyperarousal (eg, rather than going to a crowded store or isolating at home, taking a walk in a quiet park with few people). Similarly, because substance use and risky behaviors are common among veterans with PTSD and might further increase risk of suicide, exploring healthy (eg, exercise) vs unhealthy (eg, substance use; unprotected sex) coping strategies could be helpful.

Further, based on their lived experience, veterans with PTSD could experience difficulty identifying a support system or be reluctant to reach out to others during acute crisis. This might be particularly daunting in the presence of PB and TB. In these situations, it is important to validate the veteran’s difficulty with reaching out while simultaneously encouraging the veteran to examine the accuracy of such beliefs and/or helping the veteran develop skills to overcome these obstacles.

The mental health provider also can work with the individual to ensure that the veteran understands that if he or she does engage emergency resources (eg, Veterans Crisis Line), information likely will be held confidential. Providers can tell their patients that breaks in confidentiality are rare and occur only in circumstances in which it is necessary to protect the veteran. In doing so, the provider facilitates the veteran’s understanding of the role of crisis resources and clarifies any misconceptions the veteran might have (eg, calling the crisis line will always result in hospitalization or police presence).

Conclusion

Several PTSD-related factors might increase PB, TB, and the acquired capability for suicide among veterans with PTSD. Because suicide risk assessment and management can be time sensitive and anxiety provoking, mental health providers can use a TRM approach to increase their confidence in instituting optimal care and mitigating risk by having a structured, therapeutic assessment process that gathers appropriate suicide- and PTSD-related data to assist in developing suicide risk-related treatment. However, more research is needed to determine the most useful self-report measures and effective interventions when working with veterans with PTSD at risk of suicide.

Increased risk of suicide among veterans with posttraumatic stress disorder (PTSD) is well established. Posttraumatic stress disorder and related consequences are associated with higher rates of suicidal ideation and suicidal self-directed violence (S-SDV).¹ Based on a systematic review, several explanations for this relationship have been hypothesized.¹ Particular emphasis has been placed on trauma type (eg, premilitary childhood abuse, combat exposure), frequency of trauma exposure (ie, a single traumatic episode vs multiple traumatic experiences), specific PTSD symptoms (eg, avoidance, sleep disturbance, alteration in mood and cognitions, risky behaviors), and other psychosocial consequences associated with PTSD (eg, low social support, psychiatric comorbidity, substance use). However, there is limited understanding regarding how to conceptualize and assess risk for suicide when treating veterans who have PTSD.

PTSD and the Interpersonal-Psychological Theory of Suicide

Although PTSD is associated with risk for S-SDV among veterans, a diagnosis-specific approach to conceptualizing risk of suicide (ie, an explanation specific to PTSD) might not be enough because most individuals with a psychiatric diagnosis do not engage in S-SDV.² Rather, theories that are able to conceptualize suicide risk across many different psychiatric diagnoses are likely to improve mental health providers’ ability to understand risk of suicide. Although many theories attempt to understand suicide risk, the Interpersonal-Psychological Theory of Suicide (IPTS) has robust empirical support.³

The IPTS proposes that suicidal ideation is driven by perceptions of stable and unchanging thwarted belongingness (TB), defined as an unmet psychological need to socially belong, and perceived burdensomeness (PB), defined as the perception that one is a burden on others.⁴ However, PB and TB are not considered sufficient for S-SDV to occur unless an individual also has acquired the capability for suicide. Capability for suicide is thought to happen when an individual loses the fear of dying by suicide and develops tolerance to physical pain, which is proposed to occur through habituation or repeated exposure to painful stimuli.³

Several studies have examined the IPTS in a number of clinical populations, including veterans and active-duty service members; yet limited research has applied the IPTS to veterans with PTSD.³ However, a recent article proposed that a number of PTSD-related factors increase risk of suicide through the lens of the IPTS.⁵ In particular, repeated exposure to painful and provocative events—especially those characterized by violence and aggression—might increase acquired capability for suicide by causing habituation to physical pain and discomfort and reducing fear of injury and death. This concept is especially concerning because of the frequent occurrence of both military- (eg, combat, military sexual trauma) and nonmilitary-related (eg, childhood abuse, intimate partner violence) stressful and traumatic events among veterans, especially individuals with PTSD.

Moreover, the acquired capability for suicide correlates highly with anxious, intrusive, and hyperarousal symptoms of PTSD.^5-7 Over time, these PTSD symptoms are thought to increase habituation to the physically painful and frightening aspects of S-SDV, resulting in increased pain tolerance and fearlessness about death.³

In addition, PTSD-related cognitive-affective states (ie, thoughts and emotions), such as guilt, shame, and self-deprecation, might drive beliefs of PB and TB.^5,8 Repeated exposure to such trauma-related thoughts and emotions could further reinforce beliefs of self-hate or inadequacy (PB).² Trauma-related beliefs that the world or others are unsafe also might reduce the likelihood of seeking social support, thereby increasing TB.² The PTSD symptoms of avoidance and self-blame also are likely to reinforce beliefs of PB and TB.²

Assessing Suicide Risk in the Context of PTSD

The IPTS framework is one that can be used by mental health providers to conceptualize risk of suicide across populations and psychiatric diagnoses, including veterans with PTSD. However, integrating additional risk assessment and management techniques is essential to guide appropriate risk stratification and treatment.

One such method of suicide risk assessment and management is therapeutic risk management (TRM).⁹ Therapeutic risk management involves a stratification process by which temporal aspects (ie, acute and chronic) and severity (ie, low, moderate, and high) of suicide risk are assessed using a combination of clinical interview and psychometrically sound self-report measures, such as the Beck Scale for Suicide Ideation, Beck Hopelessness Scale, and Reasons for Living Inventory. Appropriate clinical interventions that correspond to acute and chronic suicide risk stratification are then implemented (eg, safety planning, lethal means counseling, increasing frequency of care, hospitalization if warranted).

Therapeutic risk management emphasizes the necessity of assessing current and past suicidal ideation, intent, plan, and access to means. Moreover, additional considerations might be indicated when assessing and conceptualizing suicide risk among veterans with PTSD. Assessing lifetime trauma history, including traumas that occurred before, during, and after military service, is important for understanding whether traumatic experiences influence acute and chronic risks of suicide. As previously described, careful attention to stressful and traumatic experiences with violent and aggressive characteristics is recommended because research suggests that these experiences are associated with increased capability for suicide.⁵ Awareness of the diversity of traumatic experiences and the importance of contextual factors surrounding such experiences also are essential. For example, the nature of violence and proximity to violence (eg, directly involved in a firefight vs hearing a mortar explosion in the distance) are key components of military-related combat trauma that might differentially influence risk of suicide.¹⁰

Similarly, although military sexual trauma can include repeated threatening sexual harassment or sexual assault, research suggests that military sexual assault is particularly important for understanding suicidal ideation, and experiences of military sexual harassment are less important.¹¹ Therefore, a careful and nuanced understanding of how contextual aspects of a veteran’s trauma history might relate to his or her chronic and acute risk of suicide is critical.

Also important is considering the individual and institutional reactions to trauma. For example, veterans whose behaviors during traumatic experiences violated their values and moral code (ie, moral injury) might be at increased risk for S-SDV. Similarly, veterans who believe that the military institution did not adequately protect them from or support them in the aftermath of traumatic experience(s) (ie, institutional betrayal) might be at higher risk of suicide.

During a clinical interview, mental health providers should pay attention to beliefs and behaviors the veteran is reporting. For example, endorsement of perceptions of low social support (eg, “no one likes me”) or self-esteem (eg, “I’m just not as good as I used to be”) might be indicative of TB or PB, respectively. Additionally, providers should be aware of current or lifetime exposure to painful stimuli (eg, nonsuicidal self-injury, such as cutting or burning, previous suicide attempts) because these exposures might increase the veteran’s acquired capability of future S-SDV.

Although unstructured clinical interviews are a common suicide risk assessment approach, TRM proposes that using a thorough clinical interview along with valid self-report measures could further illuminate a patient’s risk of suicide.⁹ Implementing brief measures allows mental health providers to quickly assess several risk factors and decrease the likelihood of missing important aspects of suicide risk assessment. Providers can use a number of measures to inform their suicide risk assessment, including augmenting a clinical interview of suicide risk with a valid self-report measure of recent suicidal ideation (eg, Beck Scale for Suicide Ideation, which assesses the severity of suicidal ideation in the past week).

Additionally for veterans with PTSD, mental health providers can include measures of PTSD symptoms (eg, PTSD checklist in the Diagnostic and Statistical Manual of Mental Disorders–5) and common PTSD comorbidities (eg, Beck Depression Inventory-II for depressive symptoms) that might contribute to current risk of suicide. Based on previous research, providers also might consider adding measures of trauma-related beliefs (eg, Posttraumatic Cognitions Inventory) and emotions, such as guilt (eg, Trauma-Related Guilt Inventory).⁵

These measures could aid in identifying modifiable risk factors of suicide among veterans with PTSD, such as the extent to which certain beliefs or emotions relate to an individual’s risk of suicide. In addition to asking about characteristics of traumatic events during the clinical interview, measures of moral injury (eg, Moral Injury Events Scale) and institutional betrayal (eg, Institutional Betrayal Questionnaire) might further inform understanding of contextual aspects of trauma that could help explain an individual’s risk of suicide.

Finally, interpersonal measures also could be helpful. For example, because avoidance and social isolation are risk factors for suicidal ideation among veterans with PTSD, measures of perceived interpersonal functioning (eg, Interpersonal Needs Questionnaire) might add further data to assist in suicide risk conceptualization. Although the selection of specific measures likely varies based on the specific needs of an individual patient, these are examples of measures that can be used with veterans with PTSD to inform suicide risk assessment and conceptualization.

By combining data from various measures across multiple domains with a thorough clinical interview, mental health providers can use a TRM approach to understand and conceptualize suicide risk among veterans with PTSD. This approach can facilitate mental health providers’ ability to provide optimal care and guide intervention(s) for veterans with PTSD. One brief intervention that has been used with veterans is safety planning. During safety planning, the provider assists the veteran in identifying warning signs, internal and external coping strategies, and individuals the veteran can reach out to for help (eg, friends and family, providers, Veterans Crisis Line), in addition to collaboratively brainstorming ways the veteran can make his or her environment safer (eg, reducing access to lethal means, identifying reminders of their reasons for living).

Specific to veterans with PTSD, symptoms such as avoidance, hyperarousal, social isolation, and beliefs that others and the world are unsafe might affect safety planning. Such symptoms could hinder identification and use of coping strategies while deterring openness to reach out to others for help. A collaborative method can be used to identify alternate means of coping that take into account PTSD-related avoidance and hyperarousal (eg, rather than going to a crowded store or isolating at home, taking a walk in a quiet park with few people). Similarly, because substance use and risky behaviors are common among veterans with PTSD and might further increase risk of suicide, exploring healthy (eg, exercise) vs unhealthy (eg, substance use; unprotected sex) coping strategies could be helpful.

Further, based on their lived experience, veterans with PTSD could experience difficulty identifying a support system or be reluctant to reach out to others during acute crisis. This might be particularly daunting in the presence of PB and TB. In these situations, it is important to validate the veteran’s difficulty with reaching out while simultaneously encouraging the veteran to examine the accuracy of such beliefs and/or helping the veteran develop skills to overcome these obstacles.

The mental health provider also can work with the individual to ensure that the veteran understands that if he or she does engage emergency resources (eg, Veterans Crisis Line), information likely will be held confidential. Providers can tell their patients that breaks in confidentiality are rare and occur only in circumstances in which it is necessary to protect the veteran. In doing so, the provider facilitates the veteran’s understanding of the role of crisis resources and clarifies any misconceptions the veteran might have (eg, calling the crisis line will always result in hospitalization or police presence).

Conclusion

Several PTSD-related factors might increase PB, TB, and the acquired capability for suicide among veterans with PTSD. Because suicide risk assessment and management can be time sensitive and anxiety provoking, mental health providers can use a TRM approach to increase their confidence in instituting optimal care and mitigating risk by having a structured, therapeutic assessment process that gathers appropriate suicide- and PTSD-related data to assist in developing suicide risk-related treatment. However, more research is needed to determine the most useful self-report measures and effective interventions when working with veterans with PTSD at risk of suicide.

Increased risk of suicide among veterans with posttraumatic stress disorder (PTSD) is well established. Posttraumatic stress disorder and related consequences are associated with higher rates of suicidal ideation and suicidal self-directed violence (S-SDV).¹ Based on a systematic review, several explanations for this relationship have been hypothesized.¹ Particular emphasis has been placed on trauma type (eg, premilitary childhood abuse, combat exposure), frequency of trauma exposure (ie, a single traumatic episode vs multiple traumatic experiences), specific PTSD symptoms (eg, avoidance, sleep disturbance, alteration in mood and cognitions, risky behaviors), and other psychosocial consequences associated with PTSD (eg, low social support, psychiatric comorbidity, substance use). However, there is limited understanding regarding how to conceptualize and assess risk for suicide when treating veterans who have PTSD.

PTSD and the Interpersonal-Psychological Theory of Suicide

Although PTSD is associated with risk for S-SDV among veterans, a diagnosis-specific approach to conceptualizing risk of suicide (ie, an explanation specific to PTSD) might not be enough because most individuals with a psychiatric diagnosis do not engage in S-SDV.² Rather, theories that are able to conceptualize suicide risk across many different psychiatric diagnoses are likely to improve mental health providers’ ability to understand risk of suicide. Although many theories attempt to understand suicide risk, the Interpersonal-Psychological Theory of Suicide (IPTS) has robust empirical support.³

The IPTS proposes that suicidal ideation is driven by perceptions of stable and unchanging thwarted belongingness (TB), defined as an unmet psychological need to socially belong, and perceived burdensomeness (PB), defined as the perception that one is a burden on others.⁴ However, PB and TB are not considered sufficient for S-SDV to occur unless an individual also has acquired the capability for suicide. Capability for suicide is thought to happen when an individual loses the fear of dying by suicide and develops tolerance to physical pain, which is proposed to occur through habituation or repeated exposure to painful stimuli.³

Several studies have examined the IPTS in a number of clinical populations, including veterans and active-duty service members; yet limited research has applied the IPTS to veterans with PTSD.³ However, a recent article proposed that a number of PTSD-related factors increase risk of suicide through the lens of the IPTS.⁵ In particular, repeated exposure to painful and provocative events—especially those characterized by violence and aggression—might increase acquired capability for suicide by causing habituation to physical pain and discomfort and reducing fear of injury and death. This concept is especially concerning because of the frequent occurrence of both military- (eg, combat, military sexual trauma) and nonmilitary-related (eg, childhood abuse, intimate partner violence) stressful and traumatic events among veterans, especially individuals with PTSD.

Moreover, the acquired capability for suicide correlates highly with anxious, intrusive, and hyperarousal symptoms of PTSD.^5-7 Over time, these PTSD symptoms are thought to increase habituation to the physically painful and frightening aspects of S-SDV, resulting in increased pain tolerance and fearlessness about death.³

In addition, PTSD-related cognitive-affective states (ie, thoughts and emotions), such as guilt, shame, and self-deprecation, might drive beliefs of PB and TB.^5,8 Repeated exposure to such trauma-related thoughts and emotions could further reinforce beliefs of self-hate or inadequacy (PB).² Trauma-related beliefs that the world or others are unsafe also might reduce the likelihood of seeking social support, thereby increasing TB.² The PTSD symptoms of avoidance and self-blame also are likely to reinforce beliefs of PB and TB.²

Assessing Suicide Risk in the Context of PTSD

The IPTS framework is one that can be used by mental health providers to conceptualize risk of suicide across populations and psychiatric diagnoses, including veterans with PTSD. However, integrating additional risk assessment and management techniques is essential to guide appropriate risk stratification and treatment.

One such method of suicide risk assessment and management is therapeutic risk management (TRM).⁹ Therapeutic risk management involves a stratification process by which temporal aspects (ie, acute and chronic) and severity (ie, low, moderate, and high) of suicide risk are assessed using a combination of clinical interview and psychometrically sound self-report measures, such as the Beck Scale for Suicide Ideation, Beck Hopelessness Scale, and Reasons for Living Inventory. Appropriate clinical interventions that correspond to acute and chronic suicide risk stratification are then implemented (eg, safety planning, lethal means counseling, increasing frequency of care, hospitalization if warranted).

Therapeutic risk management emphasizes the necessity of assessing current and past suicidal ideation, intent, plan, and access to means. Moreover, additional considerations might be indicated when assessing and conceptualizing suicide risk among veterans with PTSD. Assessing lifetime trauma history, including traumas that occurred before, during, and after military service, is important for understanding whether traumatic experiences influence acute and chronic risks of suicide. As previously described, careful attention to stressful and traumatic experiences with violent and aggressive characteristics is recommended because research suggests that these experiences are associated with increased capability for suicide.⁵ Awareness of the diversity of traumatic experiences and the importance of contextual factors surrounding such experiences also are essential. For example, the nature of violence and proximity to violence (eg, directly involved in a firefight vs hearing a mortar explosion in the distance) are key components of military-related combat trauma that might differentially influence risk of suicide.¹⁰

Similarly, although military sexual trauma can include repeated threatening sexual harassment or sexual assault, research suggests that military sexual assault is particularly important for understanding suicidal ideation, and experiences of military sexual harassment are less important.¹¹ Therefore, a careful and nuanced understanding of how contextual aspects of a veteran’s trauma history might relate to his or her chronic and acute risk of suicide is critical.

Also important is considering the individual and institutional reactions to trauma. For example, veterans whose behaviors during traumatic experiences violated their values and moral code (ie, moral injury) might be at increased risk for S-SDV. Similarly, veterans who believe that the military institution did not adequately protect them from or support them in the aftermath of traumatic experience(s) (ie, institutional betrayal) might be at higher risk of suicide.

During a clinical interview, mental health providers should pay attention to beliefs and behaviors the veteran is reporting. For example, endorsement of perceptions of low social support (eg, “no one likes me”) or self-esteem (eg, “I’m just not as good as I used to be”) might be indicative of TB or PB, respectively. Additionally, providers should be aware of current or lifetime exposure to painful stimuli (eg, nonsuicidal self-injury, such as cutting or burning, previous suicide attempts) because these exposures might increase the veteran’s acquired capability of future S-SDV.

Although unstructured clinical interviews are a common suicide risk assessment approach, TRM proposes that using a thorough clinical interview along with valid self-report measures could further illuminate a patient’s risk of suicide.⁹ Implementing brief measures allows mental health providers to quickly assess several risk factors and decrease the likelihood of missing important aspects of suicide risk assessment. Providers can use a number of measures to inform their suicide risk assessment, including augmenting a clinical interview of suicide risk with a valid self-report measure of recent suicidal ideation (eg, Beck Scale for Suicide Ideation, which assesses the severity of suicidal ideation in the past week).

Additionally for veterans with PTSD, mental health providers can include measures of PTSD symptoms (eg, PTSD checklist in the Diagnostic and Statistical Manual of Mental Disorders–5) and common PTSD comorbidities (eg, Beck Depression Inventory-II for depressive symptoms) that might contribute to current risk of suicide. Based on previous research, providers also might consider adding measures of trauma-related beliefs (eg, Posttraumatic Cognitions Inventory) and emotions, such as guilt (eg, Trauma-Related Guilt Inventory).⁵

These measures could aid in identifying modifiable risk factors of suicide among veterans with PTSD, such as the extent to which certain beliefs or emotions relate to an individual’s risk of suicide. In addition to asking about characteristics of traumatic events during the clinical interview, measures of moral injury (eg, Moral Injury Events Scale) and institutional betrayal (eg, Institutional Betrayal Questionnaire) might further inform understanding of contextual aspects of trauma that could help explain an individual’s risk of suicide.

Finally, interpersonal measures also could be helpful. For example, because avoidance and social isolation are risk factors for suicidal ideation among veterans with PTSD, measures of perceived interpersonal functioning (eg, Interpersonal Needs Questionnaire) might add further data to assist in suicide risk conceptualization. Although the selection of specific measures likely varies based on the specific needs of an individual patient, these are examples of measures that can be used with veterans with PTSD to inform suicide risk assessment and conceptualization.

By combining data from various measures across multiple domains with a thorough clinical interview, mental health providers can use a TRM approach to understand and conceptualize suicide risk among veterans with PTSD. This approach can facilitate mental health providers’ ability to provide optimal care and guide intervention(s) for veterans with PTSD. One brief intervention that has been used with veterans is safety planning. During safety planning, the provider assists the veteran in identifying warning signs, internal and external coping strategies, and individuals the veteran can reach out to for help (eg, friends and family, providers, Veterans Crisis Line), in addition to collaboratively brainstorming ways the veteran can make his or her environment safer (eg, reducing access to lethal means, identifying reminders of their reasons for living).

Specific to veterans with PTSD, symptoms such as avoidance, hyperarousal, social isolation, and beliefs that others and the world are unsafe might affect safety planning. Such symptoms could hinder identification and use of coping strategies while deterring openness to reach out to others for help. A collaborative method can be used to identify alternate means of coping that take into account PTSD-related avoidance and hyperarousal (eg, rather than going to a crowded store or isolating at home, taking a walk in a quiet park with few people). Similarly, because substance use and risky behaviors are common among veterans with PTSD and might further increase risk of suicide, exploring healthy (eg, exercise) vs unhealthy (eg, substance use; unprotected sex) coping strategies could be helpful.

Further, based on their lived experience, veterans with PTSD could experience difficulty identifying a support system or be reluctant to reach out to others during acute crisis. This might be particularly daunting in the presence of PB and TB. In these situations, it is important to validate the veteran’s difficulty with reaching out while simultaneously encouraging the veteran to examine the accuracy of such beliefs and/or helping the veteran develop skills to overcome these obstacles.

The mental health provider also can work with the individual to ensure that the veteran understands that if he or she does engage emergency resources (eg, Veterans Crisis Line), information likely will be held confidential. Providers can tell their patients that breaks in confidentiality are rare and occur only in circumstances in which it is necessary to protect the veteran. In doing so, the provider facilitates the veteran’s understanding of the role of crisis resources and clarifies any misconceptions the veteran might have (eg, calling the crisis line will always result in hospitalization or police presence).

Conclusion

Several PTSD-related factors might increase PB, TB, and the acquired capability for suicide among veterans with PTSD. Because suicide risk assessment and management can be time sensitive and anxiety provoking, mental health providers can use a TRM approach to increase their confidence in instituting optimal care and mitigating risk by having a structured, therapeutic assessment process that gathers appropriate suicide- and PTSD-related data to assist in developing suicide risk-related treatment. However, more research is needed to determine the most useful self-report measures and effective interventions when working with veterans with PTSD at risk of suicide.